Provider Demographics
NPI:1336377936
Name:WATTS, LESLIE (APRN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:WATTS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1098
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-5098
Mailing Address - Country:US
Mailing Address - Phone:606-783-1111
Mailing Address - Fax:606-784-1858
Practice Address - Street 1:155 BRICKLAYER STREET
Practice Address - Street 2:
Practice Address - City:OLIVE HILL
Practice Address - State:KY
Practice Address - Zip Code:41164
Practice Address - Country:US
Practice Address - Phone:606-286-4152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006151363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100103900Medicaid
KY0216378Medicare PIN