Healthcare Provider Details

I. General information

NPI: 1902595010
Provider Name (Legal Business Name): ANGIE WATTS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 W NORVELL BRYANT HWY
HERNANDO FL
34442-5105
US

IV. Provider business mailing address

4875 N MAPLE TER
HERNANDO FL
34442-2735
US

V. Phone/Fax

Practice location:
  • Phone: 352-249-3100
  • Fax:
Mailing address:
  • Phone: 352-436-2293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11025896
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: