Provider Demographics
NPI:1568823219
Name:NUNNERY-WILLIAMS, MARY VANESSA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:VANESSA
Last Name:NUNNERY-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 1:4336 NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-3920
Mailing Address - Country:US
Mailing Address - Phone:225-247-8388
Mailing Address - Fax:
Practice Address - Street 1:9410 LINDALE AVE STE B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70815-4160
Practice Address - Country:US
Practice Address - Phone:225-768-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
LAPLC8910171M00000X
LA8910101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator