Provider Demographics
NPI:1619938198
Name:WATKINS-GRAHAM, NERKA LAVETTE (MD)
Entity Type:Individual
Prefix:
First Name:NERKA
Middle Name:LAVETTE
Last Name:WATKINS-GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NERKA
Other - Middle Name:LAVETTE
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:134 RIVERSTONE TERRACE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-1705
Mailing Address - Country:US
Mailing Address - Phone:770-479-1985
Mailing Address - Fax:770-479-4839
Practice Address - Street 1:134 RIVERSTONE TERRACE
Practice Address - Street 2:SUITE 103
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-1705
Practice Address - Country:US
Practice Address - Phone:770-479-1985
Practice Address - Fax:770-479-4839
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046922208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000880536AMedicaid