Provider Demographics
NPI:1538875703
Name:WILLIAMS, NICOLE L (CPHT)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 NESBIT DR STE A
Mailing Address - Street 2:
Mailing Address - City:BONNE TERRE
Mailing Address - State:MO
Mailing Address - Zip Code:63628-1347
Mailing Address - Country:US
Mailing Address - Phone:573-358-3301
Mailing Address - Fax:573-358-7450
Practice Address - Street 1:60 NESBIT DR STE A
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1347
Practice Address - Country:US
Practice Address - Phone:573-358-3301
Practice Address - Fax:573-358-7450
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO15227172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker