Provider Demographics
NPI:1588281273
Name:WILLIAMS, LEATA A
Entity type:Individual
Prefix:
First Name:LEATA
Middle Name:A
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 1:2104 CROSS BRONX EXPY APT 4C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-5245
Mailing Address - Country:US
Mailing Address - Phone:347-573-1617
Mailing Address - Fax:
Practice Address - Street 1:119 W 23RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-2427
Practice Address - Country:US
Practice Address - Phone:347-573-1617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1744P3200X
NY224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No1744P3200XOther Service ProvidersSpecialistProsthetics Case Management