Healthcare Provider Details

I. General information

NPI: 1821502303
Provider Name (Legal Business Name): KRYSTAL MASHAY WATKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 JOHNSIE BILLIE HARRIS ST
EDEN NC
27288-3402
US

IV. Provider business mailing address

340 JOHNSIE BILLIE HARRIS ST
EDEN NC
27288-3402
US

V. Phone/Fax

Practice location:
  • Phone: 336-589-8530
  • Fax:
Mailing address:
  • Phone: 336-589-8530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119007535
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number11454
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: