Basic Information
| Provider Information | |||||||||
| NPI: | 1568926434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | JEANNIE | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 S WEST ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130771542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Practice Location | |||||||||
| Address1: | 2805 CINCINNATUS RD | ||||||||
| Address2: | |||||||||
| City: | CINCINNATUS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130401304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6078634126 | ||||||||
| FaxNumber: | 6077583019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2019 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 343992 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 05561739 | 05 | NY | MEDICAID |