Provider Demographics
NPI:1740582279
Name:WILLIAMS, CASARA NICHOLE
Entity Type:Individual
Prefix:MS
First Name:CASARA
Middle Name:NICHOLE
Last Name: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 1:11016 CHARLOTTE DR
Mailing Address - Street 2:
Mailing Address - City:MABELVALE
Mailing Address - State:AR
Mailing Address - Zip Code:72103-3054
Mailing Address - Country:US
Mailing Address - Phone:501-352-9843
Mailing Address - Fax:
Practice Address - Street 1:7922 OLIVE HILL DR
Practice Address - Street 2:
Practice Address - City:MABELVALE
Practice Address - State:AR
Practice Address - Zip Code:72103-3847
Practice Address - Country:US
Practice Address - Phone:501-612-1876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-04
Last Update Date:2010-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR918660211172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR181047783Medicaid