Provider Demographics
NPI:1477154888
Name:WILLIAMS, KELLI
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
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 1:8929 WENDELL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JACOB
Mailing Address - State:IL
Mailing Address - Zip Code:62281-1078
Mailing Address - Country:US
Mailing Address - Phone:618-979-9329
Mailing Address - Fax:
Practice Address - Street 1:400 JUNCTION DR
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-4323
Practice Address - Country:US
Practice Address - Phone:618-659-1395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051040695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist