Basic Information
| Provider Information | |||||||||
| NPI: | 1386865921 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMSON | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 83 UPPER RIVERDALE ROAD | ||||||||
| Address2: | BLDG 2 SUITE 135 | ||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709910778 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 83 UPPER RIVERDALE ROAD | ||||||||
| Address2: | BLDG 2 SUITE 135 | ||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709910778 | ||||||||
| FaxNumber: | 7709917390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 176B00000X | RN145364 | GA | Y | Other Service Providers | Midwife |
ID Information
| ID | Type | State | Issuer | Description | 00857601D | 05 | GA | MEDICAID |