Provider Demographics
NPI:1033864855
Name:WILLIAMSON, MIKAYLA
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 20TH ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44714-2114
Mailing Address - Country:US
Mailing Address - Phone:330-412-7253
Mailing Address - Fax:
Practice Address - Street 1:640 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-1640
Practice Address - Country:US
Practice Address - Phone:330-614-5896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH601803Medicaid