Provider Demographics
NPI:1760023154
Name:JOHNSON-WILLIAMS, ETTA MAE
Entity Type:Individual
Prefix:
First Name:ETTA
Middle Name:MAE
Last Name:JOHNSON-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 1:4054 HOULDSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-5786
Mailing Address - Country:US
Mailing Address - Phone:704-957-4266
Mailing Address - Fax:
Practice Address - Street 1:4054 HOULDSWORTH DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-5786
Practice Address - Country:US
Practice Address - Phone:704-957-4266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide