Basic Information
| Provider Information | |||||||||
| NPI: | 1174697932 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2308 S CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983622420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604575966 | ||||||||
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| Practice Location | |||||||||
| Address1: | 939 CAROLINE ST | ||||||||
| Address2: | |||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983623909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604177000 | ||||||||
| FaxNumber: | 3604177342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN00166416 | WA | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | OL0687 | 01 | RBS RIDER | OTHER | 7407786 | 05 | WA | MEDICAID |