Provider Demographics
NPI:1659149755
Name:WATTERSON, KEANNA
Entity Type:Individual
Prefix:
First Name:KEANNA
Middle Name:
Last Name:WATTERSON
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 1:26441 ROSS DR
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2964
Mailing Address - Country:US
Mailing Address - Phone:313-799-6676
Mailing Address - Fax:
Practice Address - Street 1:26115 DUNNING ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2400
Practice Address - Country:US
Practice Address - Phone:313-799-6676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health