Basic Information
| Provider Information | |||||||||
| NPI: | 1174981104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | MARLO | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | MARLO | ||||||||
| OtherMiddleName: | S. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703471235 | ||||||||
| Practice Location | |||||||||
| Address1: | 1028 N MISSOURI ST STE 6 | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723012600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704000263 | ||||||||
| FaxNumber: | 8704000293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2016 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A004586 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.