Healthcare Provider Details

I. General information

NPI: 1255934733
Provider Name (Legal Business Name): JENNIFER ANNE WILLIAMS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 E CAMELOT CIR APT 204
DECATUR IL
62526-2065
US

IV. Provider business mailing address

3970 E CAMELOT CIR APT 204
DECATUR IL
62526-2065
US

V. Phone/Fax

Practice location:
  • Phone: 217-853-4156
  • Fax:
Mailing address:
  • Phone: 217-853-4156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN195375
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.391380
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number060507043
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.022403
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: