Provider Demographics
NPI:1215403373
Name:WATSON, ROLANDA (RN)
Entity Type:Individual
Prefix:MRS
First Name:ROLANDA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:ROLANDA
Other - Middle Name:
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:IL
Mailing Address - Zip Code:60438-0334
Mailing Address - Country:US
Mailing Address - Phone:708-418-3645
Mailing Address - Fax:
Practice Address - Street 1:1900 W POLK ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3723
Practice Address - Country:US
Practice Address - Phone:312-864-7569
Practice Address - Fax:312-864-9009
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041249746163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0400XNursing Service ProvidersRegistered NurseCase ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1417195876Medicaid
IL1821305434Medicaid