Healthcare Provider Details

I. General information

NPI: 1568047728
Provider Name (Legal Business Name): EVA NICOLE WATTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2021
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E WASHINGTON ST
MEDINA OH
44256-2170
US

IV. Provider business mailing address

PO BOX 883
NOVI MI
48376-0883
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-1000
  • Fax:
Mailing address:
  • Phone: 248-420-9784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2020091763
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: