Provider Demographics
NPI:1457452948
Name:WILLIAMS, ANNIE JEAN
Entity Type:Individual
Prefix:MISS
First Name:ANNIE
Middle Name:JEAN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 S FLORISSANT RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63135-2984
Mailing Address - Country:US
Mailing Address - Phone:314-522-6414
Mailing Address - Fax:314-522-1934
Practice Address - Street 1:716 S FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63135-2984
Practice Address - Country:US
Practice Address - Phone:314-522-6414
Practice Address - Fax:314-522-1934
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0003703163W00000X, 372500000X, 374U00000X, 376J00000X
385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No163W00000XNursing Service ProvidersRegistered Nurse
No372500000XNursing Service Related ProvidersChore Provider
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO289738403Medicaid
MO269738407Medicaid