Provider Demographics
NPI:1356573463
Name:WILLIAMS, MARY SMITH (FNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:SMITH
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 E PARKVIEW ST
Mailing Address - Street 2:
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-3111
Mailing Address - Country:US
Mailing Address - Phone:731-287-7289
Mailing Address - Fax:
Practice Address - Street 1:1253 PARIS RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-4989
Practice Address - Country:US
Practice Address - Phone:270-247-2455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-23
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN95546163W00000X
IAA167618163WG0000X
TN17932363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1356573463OtherSOLE PROPRIETOR