Provider Demographics
NPI:1760499388
Name:WATTS, MARAH J (FNP)
Entity Type:Individual
Prefix:
First Name:MARAH
Middle Name:J
Last Name:WATTS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6799 GREAT OAKS RD STE 250
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2584
Mailing Address - Country:US
Mailing Address - Phone:901-685-3490
Mailing Address - Fax:
Practice Address - Street 1:6029 WALNUT GROVE RD # C002
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2112
Practice Address - Country:US
Practice Address - Phone:901-685-3490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN98603163W00000X
TNAPN11725363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3642019Medicaid
TN3642019Medicaid
TN3642019Medicare PIN
TN3642018Medicare ID - Type UnspecifiedTN MEDICARE INDIVIDUAL