Provider Demographics
NPI:1346214392
Name:WATKINS, THERESA MARIE (CNM)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21520 SULLIVAN RANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-7861
Mailing Address - Country:US
Mailing Address - Phone:352-729-4137
Mailing Address - Fax:
Practice Address - Street 1:16140 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6508
Practice Address - Country:US
Practice Address - Phone:352-360-6548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP909232367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305603100Medicaid
FL305603100Medicaid