Provider Demographics
NPI:1922250414
Name:WATT, AMY C
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:C
Last Name:WATT
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 1:404 WILSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-1357
Mailing Address - Country:US
Mailing Address - Phone:309-444-3971
Mailing Address - Fax:
Practice Address - Street 1:507 E ARMSTRONG AVENUE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-686-1177
Practice Address - Fax:309-686-7722
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL370686250001Medicaid
IL144509Medicare PIN