Provider Demographics
NPI:1295514081
Name:WILLIAMS-VARGAS, KANEZZIA
Entity type:Individual
Prefix:
First Name:KANEZZIA
Middle Name:
Last Name:WILLIAMS-VARGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KANEZZIA
Other - Middle Name:PEARL
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 STARKS PL
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-4024
Mailing Address - Country:US
Mailing Address - Phone:347-906-0890
Mailing Address - Fax:
Practice Address - Street 1:9 STARKS PL
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-4024
Practice Address - Country:US
Practice Address - Phone:347-906-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0104252081N0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081N0008XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationNeuromuscular Medicine