MEDICARE: PATRICIA WILLIAMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator
2	251E00000X	Home Health Agency	299994478	FL

General Provider Information

NPI Number	:	1053762294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA WILLIAMS

Provider Business Mailing Address
First Line	:	3364 SW CRESTVIEW RD
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-3538
Country	:	US
Telephone Number	:	772-201-8128
Fax Number	:	772-785-9190

Provider Business Practice Location Address
First Line	:	439 SE PORT ST LUCIE BLVD STE 117
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34984-5158
Country	:	US
Telephone Number	:	772-201-8128
Fax Number	:	772-785-9190

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2016
Last Update Date	:	10/14/2019

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