Provider Demographics
NPI:1619370624
Name:WILLIAMS, MICHELLE DENISE (PA)
Entity Type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:DENISE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 41516
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-1516
Mailing Address - Country:US
Mailing Address - Phone:904-202-5111
Mailing Address - Fax:904-391-5836
Practice Address - Street 1:1747 BAPTIST CLAY DR STE 230
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-8505
Practice Address - Country:US
Practice Address - Phone:904-592-1068
Practice Address - Fax:904-390-7386
Is Sole Proprietor?:No
Enumeration Date:2014-10-04
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108020363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant