Provider Demographics
NPI:1083936660
Name:WILLIAMS, NICOLE GENEVIEVE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:GENEVIEVE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N PEPPER AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-1801
Mailing Address - Country:US
Mailing Address - Phone:909-580-2186
Mailing Address - Fax:909-580-3814
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-2186
Practice Address - Fax:909-580-3814
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18786363LF0000X
390200000X
CAA1737532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program