Provider Demographics
NPI:1588225775
Name:WATSON, KRISTINE ALISON (NP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ALISON
Last Name:WATSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23457
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-3457
Mailing Address - Country:US
Mailing Address - Phone:601-200-2280
Mailing Address - Fax:601-200-8851
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:601-200-2280
Practice Address - Fax:601-200-8851
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903387363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06181203Medicaid
MS829933OtherMEDICARE