Healthcare Provider Details

I. General information

NPI: 1154883346
Provider Name (Legal Business Name): SHAINA RAE WATSON APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHAINA RAE ARCHER APRN, NP-C

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 10/23/2023
Certification Date: 10/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 W FOUNTAIN ST
ALBERT LEA MN
56007-2437
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

V. Phone/Fax

Practice location:
  • Phone: 507-373-2384
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number6522
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6522
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: