MEDICARE: MRS. LYDIA E WILLIAMS

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	163W00000X	Registered Nurse	0001241419	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86-2589470	OTHER	VA	KLACS

General Provider Information

NPI Number	:	1790360501
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYDIA E WILLIAMS

Provider Business Mailing Address
First Line	:	PO BOX 3435
Second Line	:
City	:	WARRENTON
State	:	VA
Zip	:	20188-8035
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5250 VALLEY FORGE DR APT 407
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22304-5610
Country	:	US
Telephone Number	:	703-772-3825
Fax Number	:

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

Provider Enumeration Date	:	03/12/2021
Last Update Date	:	03/12/2021

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