=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578164190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GIANNA WILLIAMS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/02/2020
-----------------------------------------------------
Last Update Date | 11/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 270 BOBBY JONES EXPY STE 158 STUDIO 23
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30907-3086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-306-1013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3114 PALM CT
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30906-3129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-306-1013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | CO107721
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------