Provider Demographics
NPI:1629677604
Name:WILLIAMS, DAMETA DIANE (MASTER ESTHETICIAN)
Entity Type:Individual
Prefix:
First Name:DAMETA
Middle Name:DIANE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MASTER ESTHETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 GREENPOINTE PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-7611
Mailing Address - Country:US
Mailing Address - Phone:260-201-2000
Mailing Address - Fax:
Practice Address - Street 1:3525 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5599
Practice Address - Country:US
Practice Address - Phone:260-201-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist