Basic Information
| Provider Information | |||||||||
| NPI: | 1750589636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATKINS | ||||||||
| FirstName: | ANGIE | ||||||||
| MiddleName: | LUCIA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAHMS | ||||||||
| OtherFirstName: | ANGIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4600 S MILL AVE STE 280 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852826850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803052888 | ||||||||
| FaxNumber: | 4803052889 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 W COLE BLVD | ||||||||
| Address2: | |||||||||
| City: | CALEXICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922319722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7603449951 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 03/30/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 200550134NP FNP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP7565 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 15453 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 238036 | 05 | AZ | MEDICAID | 500664640 | 05 | OR | MEDICAID |