Healthcare Provider Details

I. General information

NPI: 1104656776
Provider Name (Legal Business Name): LAKAN NICHOLE WILLIAMS ISC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAKAN NICHOLE WILLIAMS

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 12TH STREET EXT
PRINCETON WV
24740-2329
US

IV. Provider business mailing address

2345 MAPLE ACRES RD
PRINCETON WV
24739-7361
US

V. Phone/Fax

Practice location:
  • Phone: 304-425-9541
  • Fax: 304-425-6998
Mailing address:
  • Phone: 304-888-3152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: