Provider Demographics
NPI:1790098853
Name:WATTS, KATHRYN DEACON (CRNP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:DEACON
Last Name:WATTS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 RIDGELY AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1045
Mailing Address - Country:US
Mailing Address - Phone:410-266-8049
Mailing Address - Fax:410-266-0787
Practice Address - Street 1:600 RIDGELY AVE STE 130
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-1045
Practice Address - Country:US
Practice Address - Phone:410-266-8049
Practice Address - Fax:410-266-0787
Is Sole Proprietor?:No
Enumeration Date:2010-07-19
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR176362163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD96829004OtherBCBS
DCJ4570011OtherBCBS
MD96829002OtherBCBS
MD96829001OtherBCBS
MD96829003OtherBCBS
MD510532300Medicaid
DCD3800010OtherBCBS
DCW8490007OtherBCBS
MD192075Y97Medicare PIN
MD192075YBFHMedicare PIN