Provider Demographics
NPI:1215084785
Name:WILLIAMS, LINDA RAE (CRNA)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:RAE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2004
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918-2004
Mailing Address - Country:US
Mailing Address - Phone:304-763-6155
Mailing Address - Fax:304-763-6156
Practice Address - Street 1:127 GILEAD ST
Practice Address - Street 2:
Practice Address - City:SHADY SPRING
Practice Address - State:WV
Practice Address - Zip Code:25918-2004
Practice Address - Country:US
Practice Address - Phone:304-763-6155
Practice Address - Fax:304-763-6156
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17263367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV550771337001OtherTRICARE
WV001722480OtherBLUE CROSS BLUE SHIELD
WV5710351000Medicaid
WVLI8226281Medicare ID - Type Unspecified