Provider Demographics
NPI:1265907828
Name:WILLIAMS, MARY KATHLEEN (LVN, RN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LVN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 PAGEDALE DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-5810
Mailing Address - Country:US
Mailing Address - Phone:512-401-6722
Mailing Address - Fax:
Practice Address - Street 1:1103 PAGEDALE DRIVE
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613
Practice Address - Country:US
Practice Address - Phone:512-401-6722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX948714364SH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SH0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHome HealthGroup - Single Specialty