Provider Demographics
NPI:1083610554
Name:WILLIAMS, GWEN RENEE (CNP)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:RENEE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 CALLE DE ALVAREZ
Mailing Address - Street 2:STE B
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3821
Mailing Address - Country:US
Mailing Address - Phone:575-524-3346
Mailing Address - Fax:575-524-1720
Practice Address - Street 1:1680 CALLE DE ALVAREZ
Practice Address - Street 2:STE B
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3821
Practice Address - Country:US
Practice Address - Phone:575-524-3346
Practice Address - Fax:575-524-1720
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR50209363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85174271Medicaid
NM85174271Medicaid
NM341403006Medicare ID - Type Unspecified