Provider Demographics
NPI:1992573398
Name:WILLIAMS, PRENTISS
Entity type:Individual
Prefix:
First Name:PRENTISS
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HOWE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-4732
Mailing Address - Country:US
Mailing Address - Phone:916-485-6500
Mailing Address - Fax:
Practice Address - Street 1:650 HOWE AVE STE 300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4732
Practice Address - Country:US
Practice Address - Phone:916-485-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker