Provider Demographics
NPI:1891118279
Name:WILLIAMS, MISTY MARION
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:MARION
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 1:13440 N 44TH ST
Mailing Address - Street 2:#2205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-6351
Mailing Address - Country:US
Mailing Address - Phone:602-663-8660
Mailing Address - Fax:
Practice Address - Street 1:13440 N 44TH ST
Practice Address - Street 2:#2205
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-6351
Practice Address - Country:US
Practice Address - Phone:602-663-8660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-21
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP049552164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse