Provider Demographics
NPI:1407162209
Name:WATKINS, FANNIE FAYE (CNA-LICENSE)
Entity Type:Individual
Prefix:
First Name:FANNIE
Middle Name:FAYE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:CNA-LICENSE
Other - Prefix:
Other - First Name:FANNIE
Other - Middle Name:FAYE
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICENSE CNA
Mailing Address - Street 1:P.O. BOX 281375
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38168-1375
Mailing Address - Country:US
Mailing Address - Phone:901-282-2706
Mailing Address - Fax:
Practice Address - Street 1:3272 VALLEY STREAM CO
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128
Practice Address - Country:US
Practice Address - Phone:901-282-2706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-31
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN126228376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide