MEDICARE: MYRA WATTS FNP

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	363LF0000X	Family Nurse Practitioner	APN6294	TN
2	363LF0000X	Family Nurse Practitioner	0024126669	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417959727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYRA WATTS FNP

Provider Business Mailing Address
First Line	:	PO BOX 9
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37662-0009
Country	:	US
Telephone Number	:	423-857-2066
Fax Number	:	423-857-2070

Provider Business Practice Location Address
First Line	:	4848 FORT HENRY DR
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37663-3347
Country	:	US
Telephone Number	:	423-239-5141
Fax Number	:	423-239-4869

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

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	07/14/2015

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