Healthcare Provider Details

I. General information

NPI: 1104772771
Provider Name (Legal Business Name): DEVON REYANDRE WILLIAMS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2026
Last Update Date: 03/06/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MOSAIC COURT
ST. JOSEPH MO
64506
US

IV. Provider business mailing address

302 N 3RD ST APT 320
SAINT JOSEPH MO
64501-1797
US

V. Phone/Fax

Practice location:
  • Phone: 816-271-6000
  • Fax:
Mailing address:
  • Phone: 917-684-3842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: