Provider Demographics
NPI:1083209415
Name:WILLIAMS, SHIANNE
Entity Type:Individual
Prefix:
First Name:SHIANNE
Middle Name:
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 1:1950 DIAMOND PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-4329
Mailing Address - Country:US
Mailing Address - Phone:816-842-6717
Mailing Address - Fax:816-842-2574
Practice Address - Street 1:1950 DIAMOND PKWY STE 200
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-4329
Practice Address - Country:US
Practice Address - Phone:816-842-6717
Practice Address - Fax:816-842-2574
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-08
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2022028583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program