Provider Demographics
NPI:1023424728
Name:WILLIAMS, JOHNNY
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121A BELLEVUE RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2998
Mailing Address - Country:US
Mailing Address - Phone:478-272-1190
Mailing Address - Fax:478-274-7628
Practice Address - Street 1:2121A BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2998
Practice Address - Country:US
Practice Address - Phone:478-272-1190
Practice Address - Fax:478-274-7628
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA194363163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300030912AMedicaid
GA300030912AMedicaid