Provider Demographics
NPI:1497373492
Name:WATKINS, IRENE MARIE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:MARIE
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 1:11200 LOCKWOOD DR APT 1404
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4542
Mailing Address - Country:US
Mailing Address - Phone:301-613-5976
Mailing Address - Fax:
Practice Address - Street 1:595 MAIN ST STE 235
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4352
Practice Address - Country:US
Practice Address - Phone:240-706-7824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-07
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD620871744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty