1619370624 NPI number — MISS MICHELLE DENISE WILLIAMS P.A.

Table of content: MISS MICHELLE DENISE WILLIAMS P.A. (NPI 1619370624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619370624 NPI number — MISS MICHELLE DENISE WILLIAMS P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
MICHELLE
Provider Middle Name:
DENISE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
P.A.
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:
1619370624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41516
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32203-1516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-202-5111
Provider Business Mailing Address Fax Number:
904-391-5836

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1747 BAPTIST CLAY DR STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLEMING ISLAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32003-8505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-592-1068
Provider Business Practice Location Address Fax Number:
904-390-7386
Provider Enumeration Date:
10/04/2014

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: 363A00000X , with the licence number:  PA9108020 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016293400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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