Provider Demographics
NPI:1790427136
Name:WATSON, SAMANTHA ANNE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:ANNE
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 LADBROOK LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4849
Mailing Address - Country:US
Mailing Address - Phone:218-849-9010
Mailing Address - Fax:
Practice Address - Street 1:742 1ST ST S STE 105
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1315
Practice Address - Country:US
Practice Address - Phone:612-296-6206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2497368163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health