Healthcare Provider Details

I. General information

NPI: 1376305698
Provider Name (Legal Business Name): BONNIE YVONNE WATKINS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2024
Last Update Date: 01/24/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

5462 WHITTLESEY BLVD APT B102
COLUMBUS GA
31909-2188
US

V. Phone/Fax

Practice location:
  • Phone: 678-312-4526
  • Fax: 770-682-2219
Mailing address:
  • Phone: 602-418-2518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number1536
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: