Basic Information
| Provider Information | |||||||||
| NPI: | 1194492918 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | KEISHA | ||||||||
| MiddleName: | ANN MONIQUE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUARRIE | ||||||||
| OtherFirstName: | KEISHA | ||||||||
| OtherMiddleName: | ANN MONIQUE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2799 ROUTE 112 STE 11&7 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117632535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317325222 | ||||||||
| FaxNumber: | 6317326222 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 ROUTE 112 STE 11AND7 | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117632535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317325222 | ||||||||
| FaxNumber: | 6317326222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2021 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 381475 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.