MEDICARE: KELLY ANN WILLIAMS FNP-BC

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	657411-1	NY
2	163W00000X	Registered Nurse	852291	CA
3	363LF0000X	Family Nurse Practitioner	95000585	CA

General Provider Information

NPI Number	:	1972844371
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY ANN WILLIAMS FNP-BC

Provider Business Mailing Address
First Line	:	25825 VERMONT AVE
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-3518
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 PACIFIC COAST HWY
Second Line	:
City	:	HARBOR CITY
State	:	CA
Zip	:	90710-3509
Country	:	US
Telephone Number	:	424-328-2689
Fax Number	:

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

Provider Enumeration Date	:	03/09/2013
Last Update Date	:	12/04/2021

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