Provider Demographics
NPI:1205171097
Name:WATSON, JA-RENDA ANNISE (ANP-BC)
Entity type:Individual
Prefix:MRS
First Name:JA-RENDA
Middle Name:ANNISE
Last Name:WATSON
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 GATEWAY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2694
Mailing Address - Country:US
Mailing Address - Phone:844-388-6541
Mailing Address - Fax:
Practice Address - Street 1:6363 N STATE HIGHWAY 161 STE 100
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-2239
Practice Address - Country:US
Practice Address - Phone:469-200-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-05
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX834164363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3259186-01Medicaid
TX3259186-01Medicaid