Provider Demographics
NPI:1316050321
Name:WILLIAMS, SUSAN MARY (NP)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:MARY
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:MARY
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:441 S HAM LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3525
Mailing Address - Country:US
Mailing Address - Phone:209-365-9331
Mailing Address - Fax:209-365-9359
Practice Address - Street 1:441 S HAM LN
Practice Address - Street 2:SUITE A
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3525
Practice Address - Country:US
Practice Address - Phone:209-365-9331
Practice Address - Fax:209-365-9359
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN625718363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health