Provider Demographics
NPI:1962620112
Name:WILLIAMS, JOAN MARIE
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:M
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:1022 ROSEMARY LN
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-1858
Mailing Address - Country:US
Mailing Address - Phone:909-599-0181
Mailing Address - Fax:
Practice Address - Street 1:1022 ROSEMARY LN
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-1858
Practice Address - Country:US
Practice Address - Phone:909-599-0181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA255438163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEPS016350OtherPROVIDER #
CARVN004510OtherPROV #