Provider Demographics
NPI:1760025639
Name:WATSON, KIMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
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 314
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83680-0314
Mailing Address - Country:US
Mailing Address - Phone:208-895-6729
Mailing Address - Fax:208-855-5921
Practice Address - Street 1:1130 E FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1813
Practice Address - Country:US
Practice Address - Phone:208-895-6729
Practice Address - Fax:208-855-5921
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCNP62991363L00000X
IDNP62991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner