MEDICARE: MS. KATHLEEN EDNA WILLIAMS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	209-004303	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	209004303	OTHER	IL	STATE LICENSE
2	264325	OTHER	IL	PERSONAL CARE

General Provider Information

NPI Number	:	1063418143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHLEEN EDNA WILLIAMS APRN

Provider Business Mailing Address
First Line	:	PO BOX 78866
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53278-8666
Country	:	US
Telephone Number	:	779-696-7150
Fax Number	:

Provider Business Practice Location Address
First Line	:	1340 CHARLES ST
Second Line	:	STE 201
City	:	ROCKFORD
State	:	IL
Zip	:	61104
Country	:	US
Telephone Number	:	779-696-8799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	02/18/2021

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