Provider Demographics
NPI:1285201806
Name:WATKINS, MIESHA DAWN (LMT, NMT)
Entity Type:Individual
Prefix:
First Name:MIESHA
Middle Name:DAWN
Last Name:WATKINS
Suffix:
Gender:F
Credentials:LMT, NMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 S ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4559
Mailing Address - Country:US
Mailing Address - Phone:208-991-7560
Mailing Address - Fax:
Practice Address - Street 1:1390 S MAPLE GROVE RD STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1610
Practice Address - Country:US
Practice Address - Phone:208-672-0100
Practice Address - Fax:208-670-0200
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3735225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist