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General NPI Number Information
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NPI Number | 1033799010
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Entity Type | Individual
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Provider Name | TEQUASIA WATTS
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Gender | Female
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Dates
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Enumeration Date | 04/13/2021
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Last Update Date | 04/13/2021
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Provider Practice Location Address
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Address Line | 508 GASKIN AVE S
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City | DOUGLAS
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State | GA
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Zip | 31533-1806
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Country | US
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Telephone | 912-292-8722
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Fax |
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Provider Business Mailing Address
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Address Line | 400 ROCKBOROUGH TER
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-3848
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Country | US
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Telephone | 678-637-9984
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 034-R-2040
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License Number State | GA
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