Provider Demographics
NPI:1821454141
Name:WILLIAMSON, GLORIA SR (NP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:WILLIAMSON
Suffix:SR
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 SW NACKMAN TER
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5581
Mailing Address - Country:US
Mailing Address - Phone:772-204-2177
Mailing Address - Fax:
Practice Address - Street 1:4651 SW NACKMAN TER
Practice Address - Street 2:4015 SW MELBOURNE ST
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5581
Practice Address - Country:US
Practice Address - Phone:772-204-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9243012363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology