Provider Demographics
NPI:1588471874
Name:WILLIAMS, LARISSA NICHELLE
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:NICHELLE
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 1:163 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1066
Mailing Address - Country:US
Mailing Address - Phone:708-663-3595
Mailing Address - Fax:
Practice Address - Street 1:163 WILLOW RD
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1066
Practice Address - Country:US
Practice Address - Phone:708-663-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula