Provider Demographics
NPI:1043809445
Name:WILLIAMS, ATHENA MARIE
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:MARIE
Last Name:WILLIAMS
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 1:1120 SUMMIT BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58504-5291
Mailing Address - Country:US
Mailing Address - Phone:701-527-0828
Mailing Address - Fax:
Practice Address - Street 1:601 MEMORIAL HWY APT 2
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58504-5391
Practice Address - Country:US
Practice Address - Phone:701-527-0828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1480823Medicaid