Provider Demographics
NPI:1700325917
Name:WILLIAMS, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:CARLETTE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:8400 FRONT BEACH ROAD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32417
Mailing Address - Country:US
Mailing Address - Phone:318-229-2516
Mailing Address - Fax:
Practice Address - Street 1:8400 FRONT BEACH RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-4827
Practice Address - Country:US
Practice Address - Phone:318-229-2516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203133V00000X
FL7207133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
711909OtherREGISTERED DIETITIAN
LA203OtherREGISTERED DIETITIAN
FL7207OtherREGISTERED DIETITIAN