Healthcare Provider Details

I. General information

NPI: 1407162209
Provider Name (Legal Business Name): FANNIE FAYE WATKINS CNA-LICENSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: FANNIE FAYE WATKINS LICENSE CNA

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3272 VALLEY STREAM CO
MEMPHIS TN
38128
US

IV. Provider business mailing address

P.O. BOX 281375
MEMPHIS TN
38168-1375
US

V. Phone/Fax

Practice location:
  • Phone: 901-282-2706
  • Fax:
Mailing address:
  • Phone: 901-282-2706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number126228
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: