Provider Demographics
NPI:1184468282
Name:WILLIAMS, DEMETRIUS SHAMOND (LVN)
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:SHAMOND
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13484 COOLWATER ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-8914
Mailing Address - Country:US
Mailing Address - Phone:909-605-3300
Mailing Address - Fax:
Practice Address - Street 1:14011 PARK AVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2413
Practice Address - Country:US
Practice Address - Phone:760-843-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA249789164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse