Provider Demographics
NPI:1093091175
Name:WILLIAMS, MARY KATHERINE (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 GODWIN BLVD
Mailing Address - Street 2:SUITE 360
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8151
Mailing Address - Country:US
Mailing Address - Phone:757-539-3911
Mailing Address - Fax:757-925-0615
Practice Address - Street 1:2790 GODWIN BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8153
Practice Address - Country:US
Practice Address - Phone:757-539-3911
Practice Address - Fax:757-925-0615
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001174791367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790259HMedicaid
VA1821133174Medicaid
VA1821133174Medicaid
NC790259HMedicaid