Provider Demographics
NPI:1922573328
Name:WATZICH, LAUREN MICHELLE (PNP)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:MICHELLE
Last Name:WATZICH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:MICHELLE
Other - Last Name:QUIBODEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 ROSEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-3880
Mailing Address - Country:US
Mailing Address - Phone:714-337-2755
Mailing Address - Fax:
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011034363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics