Healthcare Provider Details

I. General information

NPI: 1124609805
Provider Name (Legal Business Name): KAYLA WILLIAMSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17520 HILLSIDE AVE
JAMAICA NY
11432-5773
US

IV. Provider business mailing address

17520 HILLSIDE AVE
JAMAICA NY
11432-5773
US

V. Phone/Fax

Practice location:
  • Phone: 718-558-7230
  • Fax:
Mailing address:
  • Phone: 718-558-7230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number778336
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number778336
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: