Provider Demographics
NPI:1295974699
Name:WILLIAMS, LARRY (RN)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7939 WESTOVER PL
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2026
Mailing Address - Country:US
Mailing Address - Phone:314-567-1912
Mailing Address - Fax:
Practice Address - Street 1:1901 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63133-1325
Practice Address - Country:US
Practice Address - Phone:314-512-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-10
Last Update Date:2009-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006037101163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice