Healthcare Provider Details

I. General information

NPI: 1124117981
Provider Name (Legal Business Name): RUTH IRINE WATTS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22101 MOROSS RD
DETROIT MI
48236-2148
US

IV. Provider business mailing address

1443 YORKSHIRE RD
GROSSE POINTE PARK MI
48230-1109
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-4766
  • Fax:
Mailing address:
  • Phone: 313-640-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704131854
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: