MEDICARE: VENNEISA SMITH WILLIAMS PT005989

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	225100000X	Physical Therapist	PT005989	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063592343
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VENNEISA SMITH WILLIAMS PT005989

Provider Business Mailing Address
First Line	:	140 RIDGE BROOK CT
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30238-5600
Country	:	US
Telephone Number	:	678-480-4172
Fax Number	:

Provider Business Practice Location Address
First Line	:	7813 SPIVEY STATION BLVD STE 230
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30236-2900
Country	:	US
Telephone Number	:	404-251-2458
Fax Number	:

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	04/12/2019

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