Provider Demographics
NPI:1639154172
Name:KING-WATTS, SUSAN (CNM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:KING-WATTS
Suffix:
Gender:F
Credentials:CNM
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 4190
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4190
Mailing Address - Country:US
Mailing Address - Phone:304-399-4405
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:143 PEYTON STREET
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504
Practice Address - Country:US
Practice Address - Phone:304-697-2035
Practice Address - Fax:304-523-1485
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV094367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0160208-000Medicaid
WVNM00872Medicare PIN
S67615Medicare UPIN