MEDICARE: MS. SALLY L. WATSON ARNP, BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	G067068	IA

General Provider Information

NPI Number	:	1093772196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SALLY L. WATSON ARNP, BC

Provider Business Mailing Address
First Line	:	4105 WOODLAND AVE
Second Line	:
City	:	DES MOINES
State	:	IA
Zip	:	50312-2720
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3600 30TH ST
Second Line	:	116A
City	:	DES MOINES
State	:	IA
Zip	:	50310-5876
Country	:	US
Telephone Number	:	515-699-5807
Fax Number	:	515-699-5779

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	07/08/2007

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