Provider Demographics
NPI:1265020044
Name:WATSON, TERRI
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
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 1:609 SAINT ANTHONY DR
Mailing Address - Street 2:
Mailing Address - City:GODFREY
Mailing Address - State:IL
Mailing Address - Zip Code:62035-2145
Mailing Address - Country:US
Mailing Address - Phone:161-856-7323
Mailing Address - Fax:
Practice Address - Street 1:609 SAINT ANTHONY DR
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-2145
Practice Address - Country:US
Practice Address - Phone:618-567-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.351942163WM0705X
IL041351942163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical