Provider Demographics
NPI:1124515440
Name:WILLIAMS, CARLLISA (RN)
Entity type:Individual
Prefix:
First Name:CARLLISA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 POYDRAS LN W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7694
Mailing Address - Country:US
Mailing Address - Phone:904-502-4851
Mailing Address - Fax:
Practice Address - Street 1:856 POYDRAS LN W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7694
Practice Address - Country:US
Practice Address - Phone:904-502-4851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2022-12-01
Deactivation Date:2018-06-13
Deactivation Code:
Reactivation Date:2022-11-25
Provider Licenses
StateLicense IDTaxonomies
FLRN9438927163W00000X, 163W00000X
251J00000X, 385H00000X
FLAPRN11022415363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No251J00000XAgenciesNursing Care
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No385H00000XRespite Care FacilityRespite Care