1407328107 NPI number — MUSU OLU SONNIE-WILLIAMS NP

Table of content: MUSU OLU SONNIE-WILLIAMS NP (NPI 1407328107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407328107 NPI number — MUSU OLU SONNIE-WILLIAMS NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SONNIE-WILLIAMS
Provider First Name:
MUSU
Provider Middle Name:
OLU
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
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:
1407328107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6897 DALE HOLLOW DR SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALEDONIA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49316-7815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-648-3246
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6897 DALE HOLLOW DR SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALEDONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49316-7815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-648-3246
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2018

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: 363L00000X , with the licence number:  4704215504 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MI8282 . This is a "MI - MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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