Healthcare Provider Details

I. General information

NPI: 1154558187
Provider Name (Legal Business Name): SHALETTA WILLIAMSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10600 TRAIN STATION DR
MABELVALE AR
72103-1644
US

IV. Provider business mailing address

829 HALBERT ST
MALVERN AR
72104-2607
US

V. Phone/Fax

Practice location:
  • Phone: 501-753-8400
  • Fax: 501-753-8401
Mailing address:
  • Phone: 501-332-4400
  • Fax: 501-332-4403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: