Provider Demographics
NPI:1841077195
Name:WILLIAMS, KENNY MARSHALL LEE
Entity type:Individual
Prefix:
First Name:KENNY
Middle Name:MARSHALL LEE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4260 COUNTY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-8169
Mailing Address - Country:US
Mailing Address - Phone:662-263-7290
Mailing Address - Fax:
Practice Address - Street 1:4260 COUNTY LAKE RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-8169
Practice Address - Country:US
Practice Address - Phone:662-263-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800309316172A00000X
MS8001683656172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty