Provider Demographics
NPI:1750371316
Name:WATKINS, SUSAN LEE (RN MSN FNP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:LEE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:RN MSN FNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LEE
Other - Last Name:PAYNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9301 N CENTRAL EXPY
Mailing Address - Street 2:STE 570
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0820
Mailing Address - Country:US
Mailing Address - Phone:817-358-5800
Mailing Address - Fax:817-283-7686
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:STE 570
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0820
Practice Address - Country:US
Practice Address - Phone:214-369-5992
Practice Address - Fax:214-369-2414
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX548208163W00000X, 164W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8D8654Medicare ID - Type Unspecified
Q50341Medicare UPIN