Provider Demographics
NPI:1073921623
Name:WILLIAMS, CONNIE SUE
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:SUE
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 1:1391 E 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-2509
Mailing Address - Country:US
Mailing Address - Phone:614-260-1135
Mailing Address - Fax:
Practice Address - Street 1:1391 E 20TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-2509
Practice Address - Country:US
Practice Address - Phone:614-260-1135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3060020Medicaid