Provider Demographics
NPI:1124610258
Name:WILLIAMS, KORY SHANESE
Entity type:Individual
Prefix:
First Name:KORY
Middle Name:SHANESE
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 1:61 CARPENTER RD N APT C5
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-7860
Mailing Address - Country:US
Mailing Address - Phone:229-566-3740
Mailing Address - Fax:
Practice Address - Street 1:61 CARPENTER RD N APT C5
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31793-7860
Practice Address - Country:US
Practice Address - Phone:229-566-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor