Provider Demographics
NPI:1285005702
Name:WILLIAMS, MARY AMANDA (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:AMANDA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6706 NURSERY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-2020
Mailing Address - Country:US
Mailing Address - Phone:803-476-4300
Mailing Address - Fax:
Practice Address - Street 1:6706 NURSERY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-2020
Practice Address - Country:US
Practice Address - Phone:803-476-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC215736163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC215736Medicaid