Provider Demographics
NPI:1093459323
Name:WATTS, TIWONA
Entity Type:Individual
Prefix:
First Name:TIWONA
Middle Name:
Last Name:WATTS
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 1:238 ADLEY WAY STE D
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6511
Mailing Address - Country:US
Mailing Address - Phone:864-706-6933
Mailing Address - Fax:
Practice Address - Street 1:238 ADLEY WAY STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6511
Practice Address - Country:US
Practice Address - Phone:864-706-6933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-22
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-1710251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC05172014Medicaid