Basic Information
| Provider Information | |||||||||
| NPI: | 1508376401 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | MCKENZIE | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 98 | ||||||||
| Address2: | |||||||||
| City: | STORY | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828420098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076807695 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1898 FORT RD | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828018320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076723473 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2017 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 225100000X | 2099 | WY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.