Provider Demographics
NPI:1821541053
Name:WILLIAMS, PAMELA DIANNE
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:DIANNE
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 1:14344 GRANDVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2943
Mailing Address - Country:US
Mailing Address - Phone:313-704-3980
Mailing Address - Fax:
Practice Address - Street 1:14344 GRANDVILLE AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2943
Practice Address - Country:US
Practice Address - Phone:313-704-3980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-23
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID423676143597247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI247200000X/TECHNICIAOtherADD TAXONOMY
MI247200000XOtherADD TAXONOMY
MI247200000X/TECHNICIAMedicaid