Healthcare Provider Details

I. General information

NPI: 1336073691
Provider Name (Legal Business Name): IVORY DENZEL WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 NE 3RD ST APT B201
MERIDIAN ID
83642-2768
US

IV. Provider business mailing address

324 NE 3RD ST APT B201
MERIDIAN ID
83642-2768
US

V. Phone/Fax

Practice location:
  • Phone: 208-791-6599
  • Fax:
Mailing address:
  • Phone: 208-791-6599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberKB158044B
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: