Provider Demographics
NPI:1073228466
Name:WATKINS, JEREMY SHANE (CNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SHANE
Last Name:WATKINS
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 NEWCOMB ST # A
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-1326
Mailing Address - Country:US
Mailing Address - Phone:540-732-7248
Mailing Address - Fax:
Practice Address - Street 1:440 NEWCOMB ST # A
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-1326
Practice Address - Country:US
Practice Address - Phone:540-732-7248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1401172821376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide