Healthcare Provider Details

I. General information

NPI: 1477449304
Provider Name (Legal Business Name): MONIQUE WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2025
Last Update Date: 06/17/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12202 BROOKGREEN DR
LOUISVILLE KY
40243-2106
US

IV. Provider business mailing address

12123 SHELBYVILLE RD STE 100
LOUISVILLE KY
40243-1079
US

V. Phone/Fax

Practice location:
  • Phone: 502-322-0712
  • Fax:
Mailing address:
  • Phone: 502-322-0712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number1152723
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: