Provider Demographics
NPI:1043888076
Name:WATKINS, MIA
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:WATKINS
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 1:9831 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-1740
Mailing Address - Country:US
Mailing Address - Phone:773-445-3500
Mailing Address - Fax:773-881-5259
Practice Address - Street 1:9831 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1740
Practice Address - Country:US
Practice Address - Phone:773-445-3500
Practice Address - Fax:773-881-5259
Is Sole Proprietor?:No
Enumeration Date:2021-06-16
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023278363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner