Provider Demographics
NPI:1114479532
Name:WILLIAMS, BENETTA
Entity Type:Individual
Prefix:
First Name:BENETTA
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 1:27400 CHARDON RD
Mailing Address - Street 2:APT 416
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44092-2901
Mailing Address - Country:US
Mailing Address - Phone:216-316-7120
Mailing Address - Fax:
Practice Address - Street 1:27400 CHARDON RD
Practice Address - Street 2:APT 416
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44092-2901
Practice Address - Country:US
Practice Address - Phone:216-316-7120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0126270Medicaid