Provider Demographics
NPI:1457357063
Name:WILLIAMSON, KATHLENE (CFNP)
Entity type:Individual
Prefix:
First Name:KATHLENE
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:KATHLENE
Other - Middle Name:SUZANNE
Other - Last Name:HODGES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:PO BOX 24023
Mailing Address - Street 2:DEPT #03-054
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-4023
Mailing Address - Country:US
Mailing Address - Phone:601-899-3989
Mailing Address - Fax:601-899-3504
Practice Address - Street 1:5903 RIDGEWOOD ROAD
Practice Address - Street 2:SUITE 440
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3702
Practice Address - Country:US
Practice Address - Phone:601-899-3989
Practice Address - Fax:601-899-3504
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN13944363L00000X
MSR530719363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S89095Medicare UPIN
MS500001699Medicare ID - Type Unspecified