=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790984631
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHNETTA WILLIAMS R.N.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2007
-----------------------------------------------------
Last Update Date | 07/12/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2302 LOWER PORT CADDO RD
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75672-2232
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-472-9274
-----------------------------------------------------
Fax | 903-938-4169
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 533
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75671-0533
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-472-9274
-----------------------------------------------------
Fax | 903-938-4169
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------