Healthcare Provider Details

I. General information

NPI: 1275168478
Provider Name (Legal Business Name): LAVERNE SHARISSE WATTS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2020
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 ALDEN ST APT L
HARTFORD CT
06114-1018
US

IV. Provider business mailing address

621 RIDGELY AVE STE 201
ANNAPOLIS MD
21401-1083
US

V. Phone/Fax

Practice location:
  • Phone: 860-372-2526
  • Fax:
Mailing address:
  • Phone: 410-224-4887
  • Fax: 410-224-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR243904
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: