Healthcare Provider Details

I. General information

NPI: 1588100697
Provider Name (Legal Business Name): ANDREA DENISE WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 KNOB HILL DR 227 KILMAINE COURT
JACKSON MS
39209-2822
US

IV. Provider business mailing address

319 KNOB HILL DR 227 KILMAINE COURT
JACKSON MS
39209-2822
US

V. Phone/Fax

Practice location:
  • Phone: 601-850-6487
  • Fax: 601-960-1776
Mailing address:
  • Phone: 601-850-6487
  • Fax: 601-960-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number801544000
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: