Provider Demographics
NPI:1801176367
Name:WILLIAMS, MARYLU (FNP)
Entity type:Individual
Prefix:
First Name:MARYLU
Middle Name:
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 1:391 SERPENTINE DR STE 500
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3083
Mailing Address - Country:US
Mailing Address - Phone:864-585-8221
Mailing Address - Fax:
Practice Address - Street 1:2755 S HIGHWAY 14 STE 2050
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4933
Practice Address - Country:US
Practice Address - Phone:864-849-9380
Practice Address - Fax:864-849-9388
Is Sole Proprietor?:No
Enumeration Date:2011-08-27
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF3367901363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00455321Medicaid
NY00455321Medicaid