Provider Demographics
NPI:1952022774
Name:WATTERS, KORI BETH
Entity Type:Individual
Prefix:
First Name:KORI
Middle Name:BETH
Last Name:WATTERS
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 1:407 W SOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601
Mailing Address - Country:US
Mailing Address - Phone:918-273-1841
Mailing Address - Fax:
Practice Address - Street 1:407 W SOUTH AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-6133
Practice Address - Country:US
Practice Address - Phone:918-273-1841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKG083831193171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator