Provider Demographics
NPI:1891316378
Name:WATSON, MAYRA LIZBETH (APRN)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:LIZBETH
Last Name:WATSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:LIZBETH
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3011 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURG
Mailing Address - State:KS
Mailing Address - Zip Code:66762-2546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1624 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:FORT SCOTT
Practice Address - State:KS
Practice Address - Zip Code:66701-2645
Practice Address - Country:US
Practice Address - Phone:620-223-8428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS79522363LF0000X
MO2014022221163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse