Healthcare Provider Details

I. General information

NPI: 1528882537
Provider Name (Legal Business Name): SAMANTHA WATKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 WILDWOOD AVE
SAINT PAUL MN
55110-1624
US

IV. Provider business mailing address

153 WILDWOOD AVE
SAINT PAUL MN
55110-1624
US

V. Phone/Fax

Practice location:
  • Phone: 612-381-6767
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number1675295
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: