Provider Demographics
NPI:1073885240
Name:WILLIAMS, REGINALD L (FNP)
Entity Type:Individual
Prefix:
First Name:REGINALD
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1074 E 84TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4228
Mailing Address - Country:US
Mailing Address - Phone:347-374-6776
Mailing Address - Fax:
Practice Address - Street 1:570 W 204TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10034-4008
Practice Address - Country:US
Practice Address - Phone:212-569-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335513-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily