Basic Information
| Provider Information | |||||||||
| NPI: | 1609050285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2800 GODWIN BLVD | ||||||||
| Address2: | FL 1 | ||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234348038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579344821 | ||||||||
| FaxNumber: | 7579344276 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 MEADE PKWY | ||||||||
| Address2: | |||||||||
| City: | SUFFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575390251 | ||||||||
| FaxNumber: | 7579342564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2007 | ||||||||
| LastUpdateDate: | 07/13/2018 | ||||||||
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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 | 0001135090 | VA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 0024164203 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1609050285 | 05 | VA | MEDICAID |