Provider Demographics
NPI:1639464845
Name:WATKINS, KENIA NICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:KENIA
Middle Name:NICHELLE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4359 TWEEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GATE
Mailing Address - State:CA
Mailing Address - Zip Code:90280-6236
Mailing Address - Country:US
Mailing Address - Phone:323-569-6979
Mailing Address - Fax:323-249-4626
Practice Address - Street 1:4359 TWEEDY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-6236
Practice Address - Country:US
Practice Address - Phone:323-569-6979
Practice Address - Fax:323-249-4626
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16377363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical