Provider Demographics
NPI:1154076040
Name:WATTS, STACY JO ANN
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JO ANN
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 1:1400 SENATE AVE STE 108
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:IA
Mailing Address - Zip Code:51566-1271
Mailing Address - Country:US
Mailing Address - Phone:712-623-7280
Mailing Address - Fax:712-623-7279
Practice Address - Street 1:1400 SENATE AVE STE 108
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-1271
Practice Address - Country:US
Practice Address - Phone:712-623-7280
Practice Address - Fax:712-623-7279
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA167711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily