Provider Demographics
NPI:1023777489
Name:WILLIAMS, CAROLINE
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12003 STATE HIGHWAY 72
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63766-6129
Mailing Address - Country:US
Mailing Address - Phone:573-275-0203
Mailing Address - Fax:
Practice Address - Street 1:2825 BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6335
Practice Address - Country:US
Practice Address - Phone:573-335-0158
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004024493133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered