Healthcare Provider Details

I. General information

NPI: 1013076579
Provider Name (Legal Business Name): ROBERTA WILLIAMS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

PO BOX 31001-0698
PASADENA CA
91110-0698
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1511
  • Fax: 602-263-1619
Mailing address:
  • Phone: 602-263-1511
  • Fax: 602-263-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN049021
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: