Provider Demographics
NPI:1013264886
Name:WILLIAMS, SHAWANA M
Entity type:Individual
Prefix:
First Name:SHAWANA
Middle Name:M
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 1:10213 W FONDULAC AVE
Mailing Address - Street 2:237
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53224-5183
Mailing Address - Country:US
Mailing Address - Phone:414-551-6872
Mailing Address - Fax:
Practice Address - Street 1:10213 W FONDULAC AVE 237
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53224-5183
Practice Address - Country:US
Practice Address - Phone:414-551-6872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIW4527937874605171WV0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WV0202XOther Service ProvidersContractorVehicle Modifications