Healthcare Provider Details

I. General information

NPI: 1033799010
Provider Name (Legal Business Name): TEQUASIA WATTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 04/13/2021
Certification Date: 04/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 GASKIN AVE S
DOUGLAS GA
31533-1806
US

IV. Provider business mailing address

400 ROCKBOROUGH TER
STONE MOUNTAIN GA
30083-3848
US

V. Phone/Fax

Practice location:
  • Phone: 912-292-8722
  • Fax:
Mailing address:
  • Phone: 678-637-9984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number034-R-2040
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: