Healthcare Provider Details

I. General information

NPI: 1578115234
Provider Name (Legal Business Name): CHANNAE WATKINS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3229 BROADWAY STE 205
GARY IN
46409-1038
US

IV. Provider business mailing address

128 S EAST ST UNIT 227
CROWN POINT IN
46308-3418
US

V. Phone/Fax

Practice location:
  • Phone: 219-806-3000
  • Fax: 219-806-3024
Mailing address:
  • Phone: 219-791-3512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009132A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: