Provider Demographics
NPI:1861224206
Name:WATKINS, BRENEA L
Entity type:Individual
Prefix:
First Name:BRENEA
Middle Name:L
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 1:3566 CASS AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2394
Mailing Address - Country:US
Mailing Address - Phone:248-873-5825
Mailing Address - Fax:
Practice Address - Street 1:3566 CASS AVE APT 301
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2394
Practice Address - Country:US
Practice Address - Phone:248-873-5825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-15
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 374U00000X, 253Z00000X
MI374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health Aide