Provider Demographics
NPI:1104464759
Name:WATKINS, NINA MARIA
Entity type:Individual
Prefix:
First Name:NINA MARIA
Middle Name:
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 1:29350 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1028
Mailing Address - Country:US
Mailing Address - Phone:248-350-6462
Mailing Address - Fax:248-357-6462
Practice Address - Street 1:29350 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1028
Practice Address - Country:US
Practice Address - Phone:248-350-6462
Practice Address - Fax:248-357-6462
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501011497225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty