Provider Demographics
NPI:1275168478
Name:WATTS, LAVERNE SHARISSE (NP)
Entity Type:Individual
Prefix:
First Name:LAVERNE
Middle Name:SHARISSE
Last Name:WATTS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 RIDGELY AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-1083
Mailing Address - Country:US
Mailing Address - Phone:410-224-4887
Mailing Address - Fax:410-224-1428
Practice Address - Street 1:37 ALDEN ST APT L
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-1018
Practice Address - Country:US
Practice Address - Phone:860-372-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-08
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR243904363L00000X
CT085053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner