Provider Demographics
NPI:1669761300
Name:WATTS, SHERONDA
Entity type:Individual
Prefix:
First Name:SHERONDA
Middle Name:
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 1:70 BUCKLAND RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-3702
Mailing Address - Country:US
Mailing Address - Phone:860-236-1300
Mailing Address - Fax:
Practice Address - Street 1:70 BUCKLAND RD
Practice Address - Street 2:SUITE E
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-3702
Practice Address - Country:US
Practice Address - Phone:860-236-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant