Healthcare Provider Details

I. General information

NPI: 1922307107
Provider Name (Legal Business Name): ANGELA MARIE WILLIAMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGELA MARIE WILLIAMS NCTMB,,MT

II. Dates (important events)

Enumeration Date: 03/27/2011
Last Update Date: 03/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 COURT ST
SUMMERSVILLE WV
26651-1416
US

IV. Provider business mailing address

504 COURT ST
SUMMERSVILLE WV
26651-1416
US

V. Phone/Fax

Practice location:
  • Phone: 304-619-4798
  • Fax: 304-619-4798
Mailing address:
  • Phone: 304-619-4798
  • Fax: 304-619-4798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number2007-2289
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number521370-06
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: