Provider Demographics
NPI:1235760166
Name:WATTERSON, MARY JO (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:WATTERSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-4514
Mailing Address - Country:US
Mailing Address - Phone:910-258-9467
Mailing Address - Fax:
Practice Address - Street 1:2511 OLD CORNWALLIS RD STE 200
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-1869
Practice Address - Country:US
Practice Address - Phone:919-932-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012779363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC14612409Medicaid