Provider Demographics
NPI:1255392528
Name:WILLIAMS EAGLETON, KIA MARIE (MSN ANP BC)
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:MARIE
Last Name:WILLIAMS EAGLETON
Suffix:
Gender:F
Credentials:MSN ANP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22402-1460
Mailing Address - Country:US
Mailing Address - Phone:540-786-2100
Mailing Address - Fax:540-786-0677
Practice Address - Street 1:111 OLDE GREENWICH DR STE 101
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-4007
Practice Address - Country:US
Practice Address - Phone:540-891-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN08813900363LA2200X
PATP005897X363LA2200X
PARN333340L363LA2200X
VA0024171616363LA2200X
NJNR08813900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ08813900OtherSTATE LICENSE
VA1255392528Medicaid
VA1255392528Medicare PIN