Healthcare Provider Details

I. General information

NPI: 1396178992
Provider Name (Legal Business Name): LINDA LUCKY WATSON X RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2013
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11545 N FRANK LLOYD WRIGHT BLVD APT 2050
SCOTTSDALE AZ
85259-3141
US

IV. Provider business mailing address

11545 N FRANK LLOYD WRIGHT BOULAVARD APT 2050
SCOTTSDALE AZ
85259-2717
US

V. Phone/Fax

Practice location:
  • Phone: 904-945-5009
  • Fax:
Mailing address:
  • Phone: 904-945-5009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number246661-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberRN111928
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN111928
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN111928
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: