Provider Demographics
NPI:1922006444
Name:WATTS, EDNA R (NP)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:R
Last Name:WATTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-0189
Mailing Address - Country:US
Mailing Address - Phone:478-987-1261
Mailing Address - Fax:478-218-0839
Practice Address - Street 1:1012 GA HIGHWAY 247 S
Practice Address - Street 2:
Practice Address - City:KATHLEEN
Practice Address - State:GA
Practice Address - Zip Code:31047-2349
Practice Address - Country:US
Practice Address - Phone:478-987-1261
Practice Address - Fax:478-218-0839
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN036579NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000812798AMedicaid
GA000812798AMedicaid
S92332Medicare UPIN