Provider Demographics
NPI:1295371649
Name:WATKINS, ANGELA LAVERNE
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:LAVERNE
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 1:17030 CARRIAGE WAY
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-6602
Mailing Address - Country:US
Mailing Address - Phone:313-949-2620
Mailing Address - Fax:
Practice Address - Street 1:22250 PROVIDENCE DR STE 406
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6212
Practice Address - Country:US
Practice Address - Phone:248-557-9010
Practice Address - Fax:248-557-3655
Is Sole Proprietor?:No
Enumeration Date:2019-11-20
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222141363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner