Provider Demographics
NPI:1760143267
Name:WATKINS, MIKAELA ROSE
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:ROSE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIKAELA
Other - Middle Name:R
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2025 GLENN MITCHELL DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-0178
Mailing Address - Country:US
Mailing Address - Phone:757-507-4123
Mailing Address - Fax:
Practice Address - Street 1:2025 GLENN MITCHELL DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-0178
Practice Address - Country:US
Practice Address - Phone:757-507-4123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008779363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant