Provider Demographics
NPI:1932986429
Name:WATKINS, THERESA LANETTE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LANETTE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:LANETTE
Other - Last Name:PANKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7023 E ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:SUN RIVER TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60964-5203
Mailing Address - Country:US
Mailing Address - Phone:815-295-1433
Mailing Address - Fax:
Practice Address - Street 1:375 N WALL ST STE P310
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3484
Practice Address - Country:US
Practice Address - Phone:815-933-0194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.453218163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse