Provider Demographics
NPI:1316562499
Name:WATHEN, JOHN DOUGLAS (RN, BSN, MSN, PMHNP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:DOUGLAS
Last Name:WATHEN
Suffix:
Gender:M
Credentials:RN, BSN, MSN, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5566 WHITEGATE CT
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:IN
Mailing Address - Zip Code:47630-8274
Mailing Address - Country:US
Mailing Address - Phone:812-589-9350
Mailing Address - Fax:
Practice Address - Street 1:415 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47713-1230
Practice Address - Country:US
Practice Address - Phone:812-423-7791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-14
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71010207A363LP0808X
IN28209048A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty