Provider Demographics
NPI:1508951039
Name:WILLIAMS, MARVA (NP)
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-261-4834
Mailing Address - Fax:314-383-3930
Practice Address - Street 1:3409 UNION BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-1127
Practice Address - Country:US
Practice Address - Phone:314-261-4834
Practice Address - Fax:314-383-3930
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO071041363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
821412451Medicare PIN