Healthcare Provider Details

I. General information

NPI: 1689002073
Provider Name (Legal Business Name): CHINIQUA WATSON HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2013
Last Update Date: 10/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3344 BANGOR CRES
CHESAPEAKE VA
23321-4449
US

IV. Provider business mailing address

3344 BANGOR CRES
CHESAPEAKE VA
23321-4449
US

V. Phone/Fax

Practice location:
  • Phone: 757-739-0149
  • Fax:
Mailing address:
  • Phone: 757-739-0149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number1201099742
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: