Healthcare Provider Details

I. General information

NPI: 1013264886
Provider Name (Legal Business Name): SHAWANA M WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2012
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10213 W FONDULAC AVE 237
MILWAUKEE WI
53224-5183
US

IV. Provider business mailing address

10213 W FONDULAC AVE 237
MILWAUKEE WI
53224-5183
US

V. Phone/Fax

Practice location:
  • Phone: 414-551-6872
  • Fax:
Mailing address:
  • Phone: 414-551-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WV0202X
TaxonomyVehicle Modifications Contractor
License NumberW4527937874605
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: