Provider Demographics
NPI:1194108811
Name:WILLIAMS, IESHA (CNP)
Entity type:Individual
Prefix:MRS
First Name:IESHA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:IESHA
Other - Middle Name:
Other - Last Name:BLAYLOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3437
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39207-3437
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:
Practice Address - Street 1:3502 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4454
Practice Address - Country:US
Practice Address - Phone:601-362-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR886570363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07336564Medicaid
AL194703Medicaid
AL194703Medicaid