Provider Demographics
NPI:1093772196
Name:WATSON, SALLY L (ARNP, BC)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:L
Last Name:WATSON
Suffix:
Gender:F
Credentials:ARNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-2720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3600 30TH ST
Practice Address - Street 2:116A
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5876
Practice Address - Country:US
Practice Address - Phone:515-699-5807
Practice Address - Fax:515-699-5779
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG067068363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health