Provider Demographics
NPI:1437345402
Name:WATSON, DEITRA ANN
Entity Type:Individual
Prefix:
First Name:DEITRA
Middle Name:ANN
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 1:1011 18TH ST N
Mailing Address - Street 2:2B
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 18TH ST N
Practice Address - Street 2:2B
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3238
Practice Address - Country:US
Practice Address - Phone:701-212-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-24
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL011245235225700000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist