Provider Demographics
NPI:1598287823
Name:WILLIAMS, KIM MACHON (HEALTH CARE SERVICE)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MACHON
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:HEALTH CARE SERVICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 QUEEN ST STE N-210
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3027
Mailing Address - Country:US
Mailing Address - Phone:757-383-4756
Mailing Address - Fax:757-673-1005
Practice Address - Street 1:2011 QUEEN ST STE N-210
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3027
Practice Address - Country:US
Practice Address - Phone:757-383-4756
Practice Address - Fax:757-673-1005
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$Medicaid