Provider Demographics
NPI:1407551286
Name:WILLIAMS, KENEIL A
Entity Type:Individual
Prefix:
First Name:KENEIL
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 MCBRIDE AVE
Mailing Address - Street 2:BUILDING 2 APT 3
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07501
Mailing Address - Country:US
Mailing Address - Phone:973-413-5590
Mailing Address - Fax:
Practice Address - Street 1:268 MCBRIDE AVE
Practice Address - Street 2:BUILDING 2 APT 3
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07501
Practice Address - Country:US
Practice Address - Phone:973-413-5590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJAG09220094363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care