Provider Demographics
NPI:1174793616
Name:WILLIAMS, RONNIE DALE (CNA , CMT)
Entity type:Individual
Prefix:MS
First Name:RONNIE
Middle Name:DALE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CNA , CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9415 THURMAN DR APT 7
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-1161
Mailing Address - Country:US
Mailing Address - Phone:208-302-0378
Mailing Address - Fax:
Practice Address - Street 1:7683 W RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-6188
Practice Address - Country:US
Practice Address - Phone:208-853-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-11
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMX060119225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID00078560602OtherIDAHONURSEAIDE PROGRAM