MEDICARE: KENNY MARSHALL LEE 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	172A00000X	Driver	800309316	MS
2	172A00000X	Driver	8001683656	MS

General Provider Information

NPI Number	:	1841077195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNY MARSHALL LEE WILLIAMS

Provider Business Mailing Address
First Line	:	4260 COUNTY LAKE RD
Second Line	:
City	:	STARKVILLE
State	:	MS
Zip	:	39759-8169
Country	:	US
Telephone Number	:	662-263-7290
Fax Number	:

Provider Business Practice Location Address
First Line	:	4260 COUNTY LAKE RD
Second Line	:
City	:	STARKVILLE
State	:	MS
Zip	:	39759-8169
Country	:	US
Telephone Number	:	662-263-7290
Fax Number	:

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

Provider Enumeration Date	:	09/11/2023
Last Update Date	:	09/11/2023

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