Provider Demographics
NPI:1770537532
Name:WILLIAMS, KIMBERLY (NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 S KING DR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2419
Mailing Address - Country:US
Mailing Address - Phone:708-705-0406
Mailing Address - Fax:
Practice Address - Street 1:2555 S KING DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2419
Practice Address - Country:US
Practice Address - Phone:708-705-0406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2017-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003787363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041-265451OtherRN LICENSE
IL209-003787OtherAPN LICENSE