MEDICARE: DEMETRIA KAY WATTS

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	3747P1801X	Personal Care Attendant	22-015477-1	IN

General Provider Information

NPI Number	:	1487362414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEMETRIA KAY WATTS

Provider Business Mailing Address
First Line	:	6803 LAKEWORTH DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4035
Country	:	US
Telephone Number	:	317-998-1289
Fax Number	:

Provider Business Practice Location Address
First Line	:	6803 LAKEWORTH DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-4035
Country	:	US
Telephone Number	:	317-998-1289
Fax Number	:

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

Provider Enumeration Date	:	11/08/2022
Last Update Date	:	11/08/2022

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