Healthcare Provider Details

I. General information

NPI: 1356041974
Provider Name (Legal Business Name): ERICA DEON WATSON NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2023
Last Update Date: 03/03/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

306 OAK PARK WAY
PEARL MS
39208-2958
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5258
  • Fax: 601-984-2652
Mailing address:
  • Phone: 601-910-9659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number905869
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: