Healthcare Provider Details

I. General information

NPI: 1316562499
Provider Name (Legal Business Name): JOHN DOUGLAS WATHEN RN, BSN, MSN, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2020
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MULBERRY ST
EVANSVILLE IN
47713-1230
US

IV. Provider business mailing address

5566 WHITEGATE CT
NEWBURGH IN
47630-8274
US

V. Phone/Fax

Practice location:
  • Phone: 812-423-7791
  • Fax:
Mailing address:
  • Phone: 812-589-9350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71010207A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number28209048A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: