Provider Demographics
NPI:1720550049
Name:WILLIAMS, MONIQUE VANESSA (CRNA)
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:VANESSA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MONIQUE
Other - Middle Name:VANESSA
Other - Last Name:WHITTICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 MEDICAL PARK RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-422-7352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-27
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN231834163W00000X
SCAPRN22505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN2856Medicaid
SCAPRN22505OtherSC BON- APRN