Provider Demographics
NPI:1083183651
Name:WATKINS, LESLIE YVONNE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:YVONNE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8621 CRENSHAW DR
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-8322
Mailing Address - Country:US
Mailing Address - Phone:254-220-6601
Mailing Address - Fax:
Practice Address - Street 1:3450 RIVER WATCH PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907
Practice Address - Country:US
Practice Address - Phone:254-220-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT011980225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist