Healthcare Provider Details

I. General information

NPI: 1306536172
Provider Name (Legal Business Name): KENNA RILEY WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 EMMA DR
CAMPOBELLO SC
29322-9295
US

IV. Provider business mailing address

50 EMMA DR
CAMPOBELLO SC
29322-9295
US

V. Phone/Fax

Practice location:
  • Phone: 910-315-3044
  • Fax:
Mailing address:
  • Phone: 910-315-3044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: