Provider Demographics
NPI:1871064717
Name:WILLIAMS HEALTHCARE SERVICES OF KENTUCKY, LLC
Entity type:Organization
Organization Name:WILLIAMS HEALTHCARE SERVICES OF KENTUCKY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:270-312-3473
Mailing Address - Street 1:585 DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-9532
Mailing Address - Country:US
Mailing Address - Phone:127-031-2347
Mailing Address - Fax:
Practice Address - Street 1:790 N DIXIE AVE STE 801
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2473
Practice Address - Country:US
Practice Address - Phone:270-234-0238
Practice Address - Fax:270-900-4764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100453830Medicaid