Provider Demographics
NPI:1639766223
Name:WILLIAMS, DEBRA GAIL (STNA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:GAIL
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 LENOX NEW LYME RD TRLR 39
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:44047-9565
Mailing Address - Country:US
Mailing Address - Phone:440-261-2337
Mailing Address - Fax:
Practice Address - Street 1:1600 LENOX NEW LYME RD TRLR 39
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047-9565
Practice Address - Country:US
Practice Address - Phone:440-261-2337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400647140707251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2903700Medicaid