Provider Demographics
NPI:1760177026
Name:WILLIAMS, NICOLE R (SUDPT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 E EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-4929
Mailing Address - Country:US
Mailing Address - Phone:360-518-9659
Mailing Address - Fax:
Practice Address - Street 1:5197 NW LOWER RIVER RD
Practice Address - Street 2:BLDG 1
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660
Practice Address - Country:US
Practice Address - Phone:360-205-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist