Provider Demographics
NPI:1578115234
Name:WATKINS, CHANNAE (NP)
Entity Type:Individual
Prefix:
First Name:CHANNAE
Middle Name:
Last Name:WATKINS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 S EAST ST UNIT 227
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46308-3418
Mailing Address - Country:US
Mailing Address - Phone:219-791-3512
Mailing Address - Fax:
Practice Address - Street 1:3229 BROADWAY STE 205
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46409-1038
Practice Address - Country:US
Practice Address - Phone:219-806-3000
Practice Address - Fax:219-806-3024
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009132A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily