Healthcare Provider Details

I. General information

NPI: 1225184401
Provider Name (Legal Business Name): MELISSA KAY WATSON CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2007
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E CARPENTER ST STE 1A
SPRINGFIELD IL
62702-5165
US

IV. Provider business mailing address

4906 MYRTLE BEACH DR
SEBRING FL
33872-1720
US

V. Phone/Fax

Practice location:
  • Phone: 217-523-0808
  • Fax: 217-523-9859
Mailing address:
  • Phone: 772-349-5495
  • Fax: 772-925-8333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: