Provider Demographics
NPI:1215197082
Name:WATTS, TALISHA LADONNA (ANP-BC)
Entity Type:Individual
Prefix:MS
First Name:TALISHA
Middle Name:LADONNA
Last Name:WATTS
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34390 COUNTRY MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-3161
Mailing Address - Country:US
Mailing Address - Phone:313-465-3550
Mailing Address - Fax:
Practice Address - Street 1:34390 COUNTRY MEADOW RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-3161
Practice Address - Country:US
Practice Address - Phone:313-465-3550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-14
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2008000145363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1215197082Medicaid
MI5008609170OtherBCBS IND
MI1215197082Medicaid