Healthcare Provider Details

I. General information

NPI: 1710299979
Provider Name (Legal Business Name): VIRGINIA ELIZABETH WILLIAMS M.ED, ATC-L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2010
Last Update Date: 07/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S SAINT MARYS ST
RALEIGH NC
27603-1699
US

IV. Provider business mailing address

115 S SAINT MARYS ST
RALEIGH NC
27603-1699
US

V. Phone/Fax

Practice location:
  • Phone: 180-036-2090
  • Fax: 186-643-4509
Mailing address:
  • Phone: 180-036-2090
  • Fax: 186-643-4509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1430
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: