Healthcare Provider Details

I. General information

NPI: 1629487806
Provider Name (Legal Business Name): DEON SHERE WATKINS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 07/21/2024
Certification Date: 07/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 W 95TH ST SUITE 301
EVERGREEN PARK IL
60805-2735
US

IV. Provider business mailing address

22412 PLUM CREEK DR
SAUK VILLAGE IL
60411-5000
US

V. Phone/Fax

Practice location:
  • Phone: 708-389-2200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209011617
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041336954
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: