Provider Demographics
NPI:1336710193
Name:WATKINS, DERRICA L
Entity Type:Individual
Prefix:
First Name:DERRICA
Middle Name:L
Last Name:WATKINS
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 1:7920 OPAL STATION DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-7784
Mailing Address - Country:US
Mailing Address - Phone:775-313-4661
Mailing Address - Fax:
Practice Address - Street 1:7920 OPAL STATION DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-7784
Practice Address - Country:US
Practice Address - Phone:775-313-4661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1770036733Medicaid