Healthcare Provider Details

I. General information

NPI: 1013783414
Provider Name (Legal Business Name): MRS. MARY ELLEN WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15802 N PARKVIEW PL
SURPRISE AZ
85374-7466
US

IV. Provider business mailing address

17565 W WINDROSE DR
SURPRISE AZ
85388-5645
US

V. Phone/Fax

Practice location:
  • Phone: 623-876-7000
  • Fax:
Mailing address:
  • Phone: 313-304-9476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN200525
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: