Provider Demographics
NPI:1588875389
Name:WILLIAMS, LARRY T I (LPN)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:T
Last Name:WILLIAMS
Suffix:I
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7460 PETUNIA DR
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30296-1186
Mailing Address - Country:US
Mailing Address - Phone:770-907-8256
Mailing Address - Fax:
Practice Address - Street 1:1701 HARDEE AVE
Practice Address - Street 2:
Practice Address - City:FORT MCPHERSON
Practice Address - State:GA
Practice Address - Zip Code:30330
Practice Address - Country:US
Practice Address - Phone:404-464-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058098164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse