Provider Demographics
NPI:1184131419
Name:WILLIAMS, JOHN BRANDON (APRN)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BRANDON
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 BALL PARK RD
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-1701
Mailing Address - Country:US
Mailing Address - Phone:660-606-5734
Mailing Address - Fax:606-487-8035
Practice Address - Street 1:37 BALL PARK RD
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-1701
Practice Address - Country:US
Practice Address - Phone:606-573-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100526410Medicaid