Provider Demographics
NPI:1568926434
Name:WILLIAMS, JEANNIE L
Entity Type:Individual
Prefix:
First Name:JEANNIE
Middle Name:L
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 1:85 S WEST ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:NY
Mailing Address - Zip Code:13077-1542
Mailing Address - Country:US
Mailing Address - Phone:607-753-3797
Mailing Address - Fax:607-753-6677
Practice Address - Street 1:2805 CINCINNATUS RD
Practice Address - Street 2:
Practice Address - City:CINCINNATUS
Practice Address - State:NY
Practice Address - Zip Code:13040-1304
Practice Address - Country:US
Practice Address - Phone:607-863-4126
Practice Address - Fax:607-758-3019
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343992363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05561739Medicaid