Provider Demographics
NPI:1447795869
Name:WILLIAMS, WANDA (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N TUCKER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63101-1000
Mailing Address - Country:US
Mailing Address - Phone:862-202-1031
Mailing Address - Fax:314-802-1583
Practice Address - Street 1:800 N TUCKER BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1000
Practice Address - Country:US
Practice Address - Phone:862-202-1031
Practice Address - Fax:314-802-1583
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015032987163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse