Provider Demographics
NPI:1083931372
Name:WATKINS, KESHA (NP-C)
Entity Type:Individual
Prefix:MS
First Name:KESHA
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 HARDEN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1800
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:803-748-9953
Practice Address - Street 1:1228 HARDEN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-1800
Practice Address - Country:US
Practice Address - Phone:803-733-5969
Practice Address - Fax:803-748-9953
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2012-07-19
Deactivation Date:2010-05-06
Deactivation Code:
Reactivation Date:2010-06-10
Provider Licenses
StateLicense IDTaxonomies
SCF4177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1834Medicaid