Provider Demographics
NPI:1194398420
Name:WATSON, LINZI BROOKE
Entity Type:Individual
Prefix:
First Name:LINZI
Middle Name:BROOKE
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 1:5200 COMMERCE CROSSINGS DR
Mailing Address - Street 2:FL 3
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-2182
Mailing Address - Country:US
Mailing Address - Phone:502-253-4924
Mailing Address - Fax:502-489-5750
Practice Address - Street 1:3058 ROCKHOUSE CRK
Practice Address - Street 2:
Practice Address - City:SALYERSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41465-7292
Practice Address - Country:US
Practice Address - Phone:606-367-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN99108053A363A00000X
KYTC108363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant