Provider Demographics
NPI:1306275672
Name:WILLIAMS, LA TONJA SHERISE
Entity type:Individual
Prefix:MRS
First Name:LA TONJA
Middle Name:SHERISE
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 1:100 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:BUNKIE
Mailing Address - State:LA
Mailing Address - Zip Code:71322-1304
Mailing Address - Country:US
Mailing Address - Phone:318-346-4091
Mailing Address - Fax:318-346-7513
Practice Address - Street 1:100 EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:BUNKIE
Practice Address - State:LA
Practice Address - Zip Code:71322-1304
Practice Address - Country:US
Practice Address - Phone:318-346-4091
Practice Address - Fax:318-346-7513
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA003342076343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)