Provider Demographics
NPI:1013627272
Name:WATTS, STEPHANIE JEAN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:JEAN
Last Name:WATTS
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 1:300 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAKARUSA
Mailing Address - State:IN
Mailing Address - Zip Code:46573-9590
Mailing Address - Country:US
Mailing Address - Phone:574-862-4511
Mailing Address - Fax:
Practice Address - Street 1:300 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAKARUSA
Practice Address - State:IN
Practice Address - Zip Code:46573-9590
Practice Address - Country:US
Practice Address - Phone:574-862-4511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN27070864A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse