Provider Demographics
NPI:1366461121
Name:WILLIAMS, MARY KAY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KAY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:701 W FRONT ST
Mailing Address - Street 2:STE 200
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2236
Mailing Address - Country:US
Mailing Address - Phone:231-346-4023
Mailing Address - Fax:231-932-7311
Practice Address - Street 1:1221 SIXTH ST STE 306
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2361
Practice Address - Country:US
Practice Address - Phone:231-935-2400
Practice Address - Fax:231-392-2424
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704123296363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP43453Medicare UPIN