Provider Demographics
NPI:1942418942
Name:WILLIAMS, IRETA J (LPN)
Entity Type:Individual
Prefix:
First Name:IRETA
Middle Name:J
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 OLIVER AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-2018
Mailing Address - Country:US
Mailing Address - Phone:914-428-8158
Mailing Address - Fax:845-208-3427
Practice Address - Street 1:150 HILL ST
Practice Address - Street 2:
Practice Address - City:MAHOPAC
Practice Address - State:NY
Practice Address - Zip Code:10541-2716
Practice Address - Country:US
Practice Address - Phone:845-628-6427
Practice Address - Fax:845-208-3427
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY14309-3164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02376589Medicaid