Provider Demographics
NPI:1225513088
Name:WILLIAMS, COURTNEY NICOLE
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:NICOLE
Other - Last Name:MESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:2100 N MARTIN LUTHER KING JR. BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-769-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM53313363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily