Provider Demographics
NPI:1942300579
Name:WILLIAMS, NICOLE M (PT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 LONG RUN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-4334
Mailing Address - Country:US
Mailing Address - Phone:502-244-8011
Mailing Address - Fax:502-244-6631
Practice Address - Street 1:1410 LONG RUN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-4334
Practice Address - Country:US
Practice Address - Phone:502-244-8011
Practice Address - Fax:502-244-6631
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2015-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004979225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000484112OtherANTHEM PIN
KY7100089270Medicaid
KY000000484112OtherANTHEM PIN