Provider Demographics
NPI:1902392137
Name:WILLIAMSON, PATRELLA
Entity Type:Individual
Prefix:
First Name:PATRELLA
Middle Name:
Last Name:WILLIAMSON
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 1:2901 CAMP COOPER DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-5881
Mailing Address - Country:US
Mailing Address - Phone:901-857-3198
Mailing Address - Fax:
Practice Address - Street 1:2201 W STAN SCHLUETER LOOP
Practice Address - Street 2:STE A 600
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549
Practice Address - Country:US
Practice Address - Phone:901-857-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1629036171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty