Provider Demographics
NPI:1609330398
Name:WILLIAMS, SHERMELL
Entity Type:Individual
Prefix:
First Name:SHERMELL
Middle Name:
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 1:4298 GREAT EGRET WAY
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-8760
Mailing Address - Country:US
Mailing Address - Phone:803-318-2052
Mailing Address - Fax:
Practice Address - Street 1:4298 GREAT EGRET WAY
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8760
Practice Address - Country:US
Practice Address - Phone:803-318-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-26
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019303600Medicaid