1295464881 NPI number — MRS. OCTAVIA KEISHA LUSANE-WILLIAMS RN

Table of content: MRS. OCTAVIA KEISHA LUSANE-WILLIAMS RN (NPI 1295464881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295464881 NPI number — MRS. OCTAVIA KEISHA LUSANE-WILLIAMS RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUSANE-WILLIAMS
Provider First Name:
OCTAVIA
Provider Middle Name:
KEISHA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295464881
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 156
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DRY BRANCH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31020-0156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-227-2799
Provider Business Mailing Address Fax Number:
478-312-9740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
625 CRABAPPLE PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31217-5575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-227-2799
Provider Business Practice Location Address Fax Number:
478-312-9740
Provider Enumeration Date:
06/08/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  RN231748 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 247ZC0005X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com