Provider Demographics
NPI:1609182708
Name:WILLIAMS, JELYN ENETE (LPN)
Entity Type:Individual
Prefix:
First Name:JELYN
Middle Name:ENETE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 E GREENWICH AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1205
Mailing Address - Country:US
Mailing Address - Phone:516-467-6910
Mailing Address - Fax:
Practice Address - Street 1:230 E GREENWICH AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1205
Practice Address - Country:US
Practice Address - Phone:516-467-6910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299097-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY299097-1OtherLPN LICENCE