Provider Demographics
NPI:1184153827
Name:WILLIAMS, STACEY (RN)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 W 24TH AVE
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46406-2821
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4747 W 24TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46406-2821
Practice Address - Country:US
Practice Address - Phone:219-240-8615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28235642A163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator