Provider Demographics
NPI:1477071348
Name:WILLIAMS, KISHA (CASE MANAGER)
Entity type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 3RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-7615
Mailing Address - Country:US
Mailing Address - Phone:580-319-6284
Mailing Address - Fax:
Practice Address - Street 1:2530 S COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5519
Practice Address - Country:US
Practice Address - Phone:580-319-7305
Practice Address - Fax:580-319-7328
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-31
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH100728830Medicaid