Provider Demographics
NPI:1962867515
Name:WATTS HALL, MAE FLORCENE
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:FLORCENE
Last Name:WATTS HALL
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 1:3698 HAYES ST NE APT 201
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-7545
Mailing Address - Country:US
Mailing Address - Phone:202-506-3376
Mailing Address - Fax:
Practice Address - Street 1:1234 MASSACHUSETTS AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20005-4526
Practice Address - Country:US
Practice Address - Phone:026-382-3822
Practice Address - Fax:202-638-3169
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-28
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA10767374U00000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC1962867515Medicaid