Healthcare Provider Details

I. General information

NPI: 1154603462
Provider Name (Legal Business Name): ANGELIQUE MARIE WILLIAMSON CM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NW 23RD ST STE 209
OKLAHOMA CITY OK
73103-1469
US

IV. Provider business mailing address

600 NW 23RD ST STE 209
OKLAHOMA CITY OK
73103-1469
US

V. Phone/Fax

Practice location:
  • Phone: 405-227-9681
  • Fax: 405-227-9081
Mailing address:
  • Phone: 405-227-9681
  • Fax: 405-227-9081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number23176
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number4873470
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: