Provider Demographics
NPI:1063592343
Name:WILLIAMS, VENNEISA SMITH (PT005989)
Entity type:Individual
Prefix:
First Name:VENNEISA
Middle Name:SMITH
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PT005989
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 RIDGE BROOK CT
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-5600
Mailing Address - Country:US
Mailing Address - Phone:678-480-4172
Mailing Address - Fax:
Practice Address - Street 1:7813 SPIVEY STATION BLVD STE 230
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-2900
Practice Address - Country:US
Practice Address - Phone:404-251-2458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT005989225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA316750186Medicaid