Provider Demographics
NPI:1487283610
Name:WILLIAMS, WALLACE Q JR
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:Q
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1336 BRYANT ST NE APT 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-1174
Mailing Address - Country:US
Mailing Address - Phone:202-705-3176
Mailing Address - Fax:
Practice Address - Street 1:1336 BRYANT ST NE APT 3
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1174
Practice Address - Country:US
Practice Address - Phone:202-705-3176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant