Healthcare Provider Details

I. General information

NPI: 1578399002
Provider Name (Legal Business Name): DIANNA MARIE WATTS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 N PROVIDENCE RD
COLUMBIA MO
65203-4308
US

IV. Provider business mailing address

31304 LACQUER AVE
MACON MO
63552-4517
US

V. Phone/Fax

Practice location:
  • Phone: 573-443-0427
  • Fax:
Mailing address:
  • Phone: 636-233-3921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number2023038065
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: