=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992111629
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KASSANDRA KAY WILLIAMS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2014
-----------------------------------------------------
Last Update Date | 11/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5449 S OCCIDENTAL RD
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49286-9782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-264-0590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5449 S OCCIDENTAL RD
-----------------------------------------------------
City | TECUMSEH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49286-9782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-506-0490
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 5601009982
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------