Healthcare Provider Details

I. General information

NPI: 1417239393
Provider Name (Legal Business Name): CAROL DENISE WATKINS CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 05/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 WILKENS AVE
BALTIMORE MD
21229-4610
US

IV. Provider business mailing address

3330 WILKENS AVE
BALTIMORE MD
21229-4610
US

V. Phone/Fax

Practice location:
  • Phone: 410-525-1544
  • Fax:
Mailing address:
  • Phone: 410-525-1544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR133381
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP019974
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: