Healthcare Provider Details

I. General information

NPI: 1023632254
Provider Name (Legal Business Name): MICHELE LEIGH WATTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELE LEIGH CLARK

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 PROVIDENCE DR
WACO TX
76707-2261
US

IV. Provider business mailing address

PO BOX 4144
WACO TX
76708-0415
US

V. Phone/Fax

Practice location:
  • Phone: 254-413-4200
  • Fax:
Mailing address:
  • Phone: 682-429-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1223563
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number684480
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: