Healthcare Provider Details

I. General information

NPI: 1962744482
Provider Name (Legal Business Name): KENDRA WATTS CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2013
Last Update Date: 03/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 SIXTH AVE STE C
PICAYUNE MS
39466-3861
US

IV. Provider business mailing address

1016 SIXTH AVE STE C
PICAYUNE MS
39466-3861
US

V. Phone/Fax

Practice location:
  • Phone: 601-799-4777
  • Fax:
Mailing address:
  • Phone: 601-799-4777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR857309
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: