Provider Demographics
NPI:1245323914
Name:WATKINS, MARY SUE (CFNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-796-7030
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1014 ROSE ST
Practice Address - Street 2:
Practice Address - City:PRENTISS
Practice Address - State:MS
Practice Address - Zip Code:39474-5271
Practice Address - Country:US
Practice Address - Phone:601-792-2071
Practice Address - Fax:601-792-8134
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR733881363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117238Medicaid
MSP00445055OtherRAILROAD MEDICARE
MSS29082Medicare UPIN
MS00117238Medicaid