Healthcare Provider Details

I. General information

NPI: 1669609764
Provider Name (Legal Business Name): LISA MARIE WATSON MHPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE WILBANKS

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 04/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 W. MAIN STREET
WALNUT RIDGE AR
72476-1431
US

IV. Provider business mailing address

1815 PLEASANT GROVE ROAD
JONESBORO AR
72401-7870
US

V. Phone/Fax

Practice location:
  • Phone: 870-886-5303
  • Fax: 870-886-7002
Mailing address:
  • Phone: 870-933-6886
  • Fax: 870-933-9395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: