Provider Demographics
NPI:1093312878
Name:WILLIAMS, DEVON MARIE
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:MARIE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:TIPP CITY
Mailing Address - State:OH
Mailing Address - Zip Code:45371-1729
Mailing Address - Country:US
Mailing Address - Phone:937-269-7890
Mailing Address - Fax:
Practice Address - Street 1:503 DURST DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2323
Practice Address - Country:US
Practice Address - Phone:937-269-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0157782Medicaid