Provider Demographics
NPI:1417384009
Name:WATKIS, KRISTAL DENISE (LPN)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:DENISE
Last Name:WATKIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 DALE AVE APT D10
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505-1936
Mailing Address - Country:US
Mailing Address - Phone:804-647-2352
Mailing Address - Fax:
Practice Address - Street 1:12 DALE AVE APT D10
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07505-1936
Practice Address - Country:US
Practice Address - Phone:804-647-2352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-27
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY314346164W00000X
VA2073714164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse