Healthcare Provider Details

I. General information

NPI: 1528453933
Provider Name (Legal Business Name): CONNIE T WATTS AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CONNIE CHITWOOD AGACNP

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 09/25/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 KING AVENUE, SUITE 210
ATHENS GA
30606
US

IV. Provider business mailing address

PO BOX 742616
ATLANTA GA
30374-2616
US

V. Phone/Fax

Practice location:
  • Phone: 706-475-1700
  • Fax:
Mailing address:
  • Phone: 770-219-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN118797
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN118797
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: