=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124258694
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAMARA C WATKINS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2009
-----------------------------------------------------
Last Update Date | 07/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1304 KELLOGG DR
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-4942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-508-5344
-----------------------------------------------------
Fax | 352-508-5577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1304 KELLOGG DR
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-4942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-508-5344
-----------------------------------------------------
Fax | 352-508-5577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 693702101
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------