Provider Demographics
NPI:1922383264
Name:WILLIAMS, FANNIE LAURA (NP)
Entity Type:Individual
Prefix:
First Name:FANNIE
Middle Name:LAURA
Last Name:WILLIAMS
Suffix:
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 1:8300 HOUGH AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-4247
Mailing Address - Country:US
Mailing Address - Phone:216-231-7700
Mailing Address - Fax:216-231-7920
Practice Address - Street 1:8300 HOUGH AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44103-4247
Practice Address - Country:US
Practice Address - Phone:216-231-7700
Practice Address - Fax:216-231-7920
Is Sole Proprietor?:No
Enumeration Date:2011-10-19
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.12676-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0055717Medicaid
H409200Medicare PIN