Provider Demographics
NPI:1952060436
Name:WILLIAMS, OMOTAYO A
Entity Type:Individual
Prefix:
First Name:OMOTAYO
Middle Name:A
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 1:3303 DODGE PARK RD APT 202
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-2106
Mailing Address - Country:US
Mailing Address - Phone:301-232-8877
Mailing Address - Fax:
Practice Address - Street 1:721 48TH ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-3607
Practice Address - Country:US
Practice Address - Phone:202-541-9844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00166099376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide