Healthcare Provider Details

I. General information

NPI: 1861035347
Provider Name (Legal Business Name): SERENA RAE WILLIAMS CLC, CD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2019
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date: 11/02/2021
Reactivation Date: 08/11/2022

III. Provider practice location address

622 CARLISLE AVE
DAYTON OH
45410-2737
US

IV. Provider business mailing address

622 CARLISLE AVE
DAYTON OH
45410-2737
US

V. Phone/Fax

Practice location:
  • Phone: 937-522-1816
  • Fax:
Mailing address:
  • Phone: 937-522-1816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: