Healthcare Provider Details

I. General information

NPI: 1578013249
Provider Name (Legal Business Name): ANGELA WILLIAX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 2 BOX 150A
ELIZABETHTOWN IL
62931-9787
US

IV. Provider business mailing address

RR 2 BOX 150A
ELIZABETHTOWN IL
62931-9787
US

V. Phone/Fax

Practice location:
  • Phone: 618-518-0855
  • Fax:
Mailing address:
  • Phone: 618-518-0855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043.075268
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: