Basic Information
| Provider Information | |||||||||
| NPI: | 1063592343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | VENNEISA | ||||||||
| MiddleName: | SMITH | ||||||||
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| Credential: | PT005989 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 140 RIDGE BROOK CT | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302385600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784804172 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7813 SPIVEY STATION BLVD STE 230 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302362900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042512458 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 04/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT005989 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 316750186 | 05 | GA | MEDICAID |