Provider Demographics
NPI:1760134464
Name:WILLIAMS, AMANDA CORTLYNE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CORTLYNE
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 1:3140 BELVEDERE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3205
Mailing Address - Country:US
Mailing Address - Phone:951-866-3410
Mailing Address - Fax:
Practice Address - Street 1:3148 BELVEDERE DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3205
Practice Address - Country:US
Practice Address - Phone:951-850-9745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE1234700OtherDRIVER LICENSE