Basic Information
| Provider Information | |||||||||
| NPI: | 1700444056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10051 LACEY DR | ||||||||
| Address2: | |||||||||
| City: | OLIVE BRANCH | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386548413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018716472 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3360 N WATKINS ST | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381276432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014017150 | ||||||||
| FaxNumber: | 9013471285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2019 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 25620 | TN | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.