Healthcare Provider Details

I. General information

NPI: 1417223777
Provider Name (Legal Business Name): AMANDA JEAN WATKINS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2012
Last Update Date: 08/21/2021
Certification Date: 08/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 S SALEM ST
APEX NC
27502-1825
US

IV. Provider business mailing address

212 S SALEM ST
APEX NC
27502-1825
US

V. Phone/Fax

Practice location:
  • Phone: 919-362-5201
  • Fax:
Mailing address:
  • Phone: 919-362-5201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN208871
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5005760
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: