MEDICARE: T-VIONNE JAQUAY WATKINS LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	162174	OH

General Provider Information

NPI Number	:	1467922641
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	T-VIONNE JAQUAY WATKINS LPN

Provider Business Mailing Address
First Line	:	3093 BECKET RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-2709
Country	:	US
Telephone Number	:	216-990-4840
Fax Number	:

Provider Business Practice Location Address
First Line	:	3093 BECKET RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44120-2709
Country	:	US
Telephone Number	:	216-990-4840
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2018
Last Update Date	:	11/29/2018

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