Healthcare Provider Details

I. General information

NPI: 1356573463
Provider Name (Legal Business Name): MARY SMITH WILLIAMS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2009
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1253 PARIS RD
MAYFIELD KY
42066-4989
US

IV. Provider business mailing address

433 E PARKVIEW ST
DYERSBURG TN
38024-3111
US

V. Phone/Fax

Practice location:
  • Phone: 270-247-2455
  • Fax:
Mailing address:
  • Phone: 731-287-7289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95546
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberA167618
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17932
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: