Provider Demographics
NPI:1629343660
Name:SMALL-WILLIAMS, EVEREST L
Entity Type:Individual
Prefix:
First Name:EVEREST
Middle Name:L
Last Name:SMALL-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 1:167 MORNINGSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4619
Mailing Address - Country:US
Mailing Address - Phone:203-522-5861
Mailing Address - Fax:
Practice Address - Street 1:167 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4619
Practice Address - Country:US
Practice Address - Phone:203-522-5861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219265-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse