Healthcare Provider Details

I. General information

NPI: 1720585235
Provider Name (Legal Business Name): AMANDA MARIE WATSON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA MARIE CIERVO

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 CROWN ST
BRISTOL CT
06010-6125
US

IV. Provider business mailing address

224 CROWN ST
BRISTOL CT
06010-6125
US

V. Phone/Fax

Practice location:
  • Phone: 860-877-3157
  • Fax:
Mailing address:
  • Phone: 860-877-3157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12.007329
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10.106646
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: