Provider Demographics
NPI:1821704974
Name:WILLIAMS, DEMETRE DELINE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:DEMETRE
Middle Name:DELINE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 BEHLMANN FARMS CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2859
Mailing Address - Country:US
Mailing Address - Phone:314-495-5450
Mailing Address - Fax:
Practice Address - Street 1:11642 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6723
Practice Address - Country:US
Practice Address - Phone:314-838-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023006453363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily