Provider Demographics
NPI:1942815659
Name:WATSON, CONNIE NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:NICOLE
Last Name:WATSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1539 N PARKWAY APT A
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-4913
Mailing Address - Country:US
Mailing Address - Phone:615-681-6005
Mailing Address - Fax:
Practice Address - Street 1:3965 S MENDENHALL RD STE 20
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-5954
Practice Address - Country:US
Practice Address - Phone:901-620-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13113225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist