Healthcare Provider Details

I. General information

NPI: 1457038382
Provider Name (Legal Business Name): KEYANNA D WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 COURTLEIGH DR
RANDALLSTOWN MD
21133-4806
US

IV. Provider business mailing address

3640 CONCORD PIKE
WILMINGTON DE
19803-5022
US

V. Phone/Fax

Practice location:
  • Phone: 443-392-6934
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: