MEDICARE: CONNIE 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	133V00000X	Registered Dietitian	203	LA
2	133V00000X	Registered Dietitian	7207	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	711909	OTHER		REGISTERED DIETITIAN
2	203	OTHER	LA	REGISTERED DIETITIAN
3	7207	OTHER	FL	REGISTERED DIETITIAN

General Provider Information

NPI Number	:	1700325917
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE WILLIAMS

Provider Business Mailing Address
First Line	:	8400 FRONT BEACH ROAD
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32417
Country	:	US
Telephone Number	:	318-229-2516
Fax Number	:

Provider Business Practice Location Address
First Line	:	8400 FRONT BEACH RD
Second Line	:
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32407-4827
Country	:	US
Telephone Number	:	318-229-2516
Fax Number	:

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

Provider Enumeration Date	:	02/21/2017
Last Update Date	:	02/21/2017

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Directions to “ CONNIE WILLIAMS ” Practice Location

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