Provider Demographics
NPI:1699537969
Name:WILLIAMS, NICOLE (CRNA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 VERGELAND DR
Mailing Address - Street 2:
Mailing Address - City:HOPE MILLS
Mailing Address - State:NC
Mailing Address - Zip Code:28348-7549
Mailing Address - Country:US
Mailing Address - Phone:715-965-6009
Mailing Address - Fax:
Practice Address - Street 1:300 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3075
Practice Address - Country:US
Practice Address - Phone:910-671-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX741019163W00000X
NC153000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No163W00000XNursing Service ProvidersRegistered Nurse