Provider Demographics
NPI:1134664899
Name:WATSON, SERGIO (LPN)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 IRENE RD
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-1313
Mailing Address - Country:US
Mailing Address - Phone:216-931-6532
Mailing Address - Fax:
Practice Address - Street 1:1131 IRENE RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124
Practice Address - Country:US
Practice Address - Phone:216-931-6532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH161422164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse