Provider Demographics
NPI:1740251446
Name:WATTERWORTH, CAROLYN C (CRNA)
Entity type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:C
Last Name:WATTERWORTH
Suffix:
Gender:F
Credentials:CRNA
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 951568
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193
Mailing Address - Country:US
Mailing Address - Phone:937-293-0247
Mailing Address - Fax:937-293-0960
Practice Address - Street 1:1141 N MONROE DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385
Practice Address - Country:US
Practice Address - Phone:937-372-8011
Practice Address - Fax:937-376-6983
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN161162367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00281504OtherRAILROAD MEDICARE
OH000000381924OtherANTHEM
OH0806980Medicaid
OH0806980Medicaid