Provider Demographics
NPI:1295464881
Name:LUSANE-WILLIAMS, OCTAVIA KEISHA (RN)
Entity type:Individual
Prefix:MRS
First Name:OCTAVIA
Middle Name:KEISHA
Last Name:LUSANE-WILLIAMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:DRY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:31020-0156
Mailing Address - Country:US
Mailing Address - Phone:478-227-2799
Mailing Address - Fax:478-312-9740
Practice Address - Street 1:625 CRABAPPLE PL
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-5575
Practice Address - Country:US
Practice Address - Phone:478-227-2799
Practice Address - Fax:478-312-9740
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN231748163W00000X
247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
No163W00000XNursing Service ProvidersRegistered Nurse