Provider Demographics
NPI:1467922641
Name:WATKINS, T-VIONNE JAQUAY (LPN)
Entity Type:Individual
Prefix:
First Name:T-VIONNE
Middle Name:JAQUAY
Last Name:WATKINS
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 1:3093 BECKET RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-2709
Mailing Address - Country:US
Mailing Address - Phone:216-990-4840
Mailing Address - Fax:
Practice Address - Street 1:3093 BECKET RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-2709
Practice Address - Country:US
Practice Address - Phone:216-990-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH162174164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid