Provider Demographics
NPI:1356848196
Name:WATSON, LORI LEANNE
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:LEANNE
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 1:2216 SASSAFRAS DR
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37128-5661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2216 SASSAFRAS DR
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37128-5661
Practice Address - Country:US
Practice Address - Phone:615-631-0827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN172012163W00000X
TN23429363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse