Healthcare Provider Details

I. General information

NPI: 1457186215
Provider Name (Legal Business Name): BRANDI LYNN WATT DNP, APRN, NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 CORONADO ST
IDAHO FALLS ID
83404-7407
US

IV. Provider business mailing address

4580 LONG BOW BND
IDAHO FALLS ID
83406-4935
US

V. Phone/Fax

Practice location:
  • Phone: 208-557-2700
  • Fax:
Mailing address:
  • Phone: 208-681-2610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number8361274
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number8361274
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: