Provider Demographics
NPI:1629238787
Name:WILLIAMS, KELLIE NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLIE
Middle Name:NICOLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLIE
Other - Middle Name:NICOLE
Other - Last Name:GOFORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:315 N SAN SABA STE 11
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3154
Mailing Address - Country:US
Mailing Address - Phone:210-704-3321
Mailing Address - Fax:
Practice Address - Street 1:315 N SAN SABA STE 11
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3154
Practice Address - Country:US
Practice Address - Phone:210-704-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012494472080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine