Provider Demographics
NPI:1720585235
Name:WATSON, AMANDA MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:CIERVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:224 CROWN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-6125
Mailing Address - Country:US
Mailing Address - Phone:860-877-3157
Mailing Address - Fax:
Practice Address - Street 1:224 CROWN ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6125
Practice Address - Country:US
Practice Address - Phone:860-877-3157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10.106646163W00000X
CT12.007329363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse