Healthcare Provider Details

I. General information

NPI: 1639745904
Provider Name (Legal Business Name): ELLEN PETERS WILLIAMS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2021
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1896 HIGHWAY 471
BRANDON MS
39047-7964
US

IV. Provider business mailing address

365 CREEKSIDE DR
CHEROKEE AL
35616-6339
US

V. Phone/Fax

Practice location:
  • Phone: 601-665-4162
  • Fax:
Mailing address:
  • Phone: 256-412-1344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number904635
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: