Provider Demographics
NPI:1821645789
Name:WATSON, MALISSA
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:
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 1:80 HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:NY
Mailing Address - Zip Code:14883-9589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:80 HOWELL RD
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:NY
Practice Address - Zip Code:14883-9589
Practice Address - Country:US
Practice Address - Phone:607-279-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-23
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily