Provider Demographics
NPI:1679636591
Name:WILLIAMS, KENNETH A (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1001
Mailing Address - Street 2:
Mailing Address - City:IONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48846-6001
Mailing Address - Country:US
Mailing Address - Phone:616-527-4200
Mailing Address - Fax:616-527-5731
Practice Address - Street 1:479 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-1834
Practice Address - Country:US
Practice Address - Phone:616-527-4200
Practice Address - Fax:616-527-5731
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704189497367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704189497OtherSTATE LICENSE NUMBER
MIM92890025Medicare ID - Type Unspecified