Provider Demographics
NPI:1790097012
Name:WILLIAMS, SHANNON D (CAS,)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CAS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 BROOKSTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3730
Mailing Address - Country:US
Mailing Address - Phone:336-721-2938
Mailing Address - Fax:
Practice Address - Street 1:690 BROOKSTOWN AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3730
Practice Address - Country:US
Practice Address - Phone:336-721-2938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC64198174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist