Provider Demographics
NPI:1861544249
Name:WILLIAMS, MARA SUSAN
Entity type:Individual
Prefix:MRS
First Name:MARA
Middle Name:SUSAN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARTHA
Other - Middle Name:
Other - Last Name:BLOCK, DONNELLY, PALMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:19337 ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-6215
Mailing Address - Country:US
Mailing Address - Phone:707-996-6219
Mailing Address - Fax:
Practice Address - Street 1:3417 VALLE VERDE DR
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2414
Practice Address - Country:US
Practice Address - Phone:707-255-4172
Practice Address - Fax:707-255-2605
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA345522363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA15902OtherNP FURNISHING NUMBER
CA15902OtherNP CERTIFICATE NUMBER
CA345522OtherRN LICENSE
CA345522OtherRN LICENSE