Provider Demographics
NPI:1114631199
Name:WATSON, HOSTRAYAH FAUSTINA
Entity Type:Individual
Prefix:MRS
First Name:HOSTRAYAH
Middle Name:FAUSTINA
Last Name:WATSON
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 1:13510 TERRACE CREEK DR APT 202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5842
Mailing Address - Country:US
Mailing Address - Phone:267-370-1758
Mailing Address - Fax:
Practice Address - Street 1:13510 TERRACE CREEK DR APT 202
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5842
Practice Address - Country:US
Practice Address - Phone:267-370-1758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-13
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY274914225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist