Healthcare Provider Details

I. General information

NPI: 1639380447
Provider Name (Legal Business Name): SANDRA K. WILLIAMS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 05/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 OLIVE BLVD 4TH FLOOR
SAINT LOUIS MO
63141-6362
US

IV. Provider business mailing address

PO BOX 23340
SAINT LOUIS MO
63156-3340
US

V. Phone/Fax

Practice location:
  • Phone: 314-517-4832
  • Fax: 314-851-4445
Mailing address:
  • Phone: 314-517-4832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number061769
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number061769
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209-004555
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: