MEDICARE: KATHLENE WILLIAMSON C.F.N.P.

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	APN13944	TN
2	363LF0000X	Family Nurse Practitioner	R530719	MS

General Provider Information

NPI Number	:	1457357063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLENE WILLIAMSON C.F.N.P.

Provider Business Mailing Address
First Line	:	PO BOX 24023
Second Line	:	DEPT #03-054
City	:	JACKSON
State	:	MS
Zip	:	39225-4023
Country	:	US
Telephone Number	:	601-899-3989
Fax Number	:	601-899-3504

Provider Business Practice Location Address
First Line	:	5903 RIDGEWOOD ROAD
Second Line	:	SUITE 440
City	:	JACKSON
State	:	MS
Zip	:	39211-3702
Country	:	US
Telephone Number	:	601-899-3989
Fax Number	:	601-899-3504

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

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	04/05/2012

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