Healthcare Provider Details

I. General information

NPI: 1285628461
Provider Name (Legal Business Name): MARYJO A WATKINS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MEMORIAL DR ANESTHESIA DEPT
PINEHURST NC
28374-8710
US

IV. Provider business mailing address

PO BOX 99
LEWISVILLE NC
27023-0099
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-1235
  • Fax:
Mailing address:
  • Phone: 731-234-2335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number10681
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: