=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346698032
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN JOANNE WATKINS RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2016
-----------------------------------------------------
Last Update Date | 06/02/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5199 NW ELM AVE
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97756-8898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-350-6463
-----------------------------------------------------
Fax | 541-923-6462
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5199 NW ELM AVE
-----------------------------------------------------
City | REDMOND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97756-8898
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-350-6463
-----------------------------------------------------
Fax | 541-923-6462
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WL0100X
-----------------------------------------------------
Taxonomy Name | Lactation Consultant (Registered Nurse)
-----------------------------------------------------
License Number | 089003112RN
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------