Provider Demographics
NPI:1790454916
Name:WILLIAMS, PEACHES
Entity Type:Individual
Prefix:
First Name:PEACHES
Middle Name:
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 1:1216 HODGE LANE
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:MS
Mailing Address - Zip Code:39066
Mailing Address - Country:US
Mailing Address - Phone:601-473-1325
Mailing Address - Fax:
Practice Address - Street 1:345 WOODSTONE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4945
Practice Address - Country:US
Practice Address - Phone:601-473-1325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS682374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide