Provider Demographics
NPI:1265848840
Name:WILLIAMS, PHOEBE
Entity type:Individual
Prefix:
First Name:PHOEBE
Middle Name:
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 1:4006 E REGNAS AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617-6830
Mailing Address - Country:US
Mailing Address - Phone:813-751-6817
Mailing Address - Fax:813-899-0420
Practice Address - Street 1:4006 E REGNAS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-6830
Practice Address - Country:US
Practice Address - Phone:813-751-6817
Practice Address - Fax:813-899-0420
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6905166311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141498400Medicaid