Provider Demographics
NPI:1215687637
Name:WILLIAMS, ALICIA JUVONNA (PMHNP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:JUVONNA
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-7311
Mailing Address - Country:US
Mailing Address - Phone:417-322-6622
Mailing Address - Fax:417-350-1935
Practice Address - Street 1:2005 W ELM ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-4018
Practice Address - Country:US
Practice Address - Phone:479-427-7722
Practice Address - Fax:479-427-7721
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022035598363LP0808X
ARR081570163W00000X
AR218003363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420115020Medicaid
AR281639758Medicaid
ARR081570OtherARKANSAS RN LICENSE
MO420115020Medicaid