Provider Demographics
NPI:1053762294
Name:WILLIAMS, PATRICIA
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3364 SW CRESTVIEW RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3538
Mailing Address - Country:US
Mailing Address - Phone:772-201-8128
Mailing Address - Fax:772-785-9190
Practice Address - Street 1:439 SE PORT ST LUCIE BLVD STE 117
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-5158
Practice Address - Country:US
Practice Address - Phone:772-201-8128
Practice Address - Fax:772-785-9190
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FL299994478251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator