=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720140452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATIE M WATTS LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2006
-----------------------------------------------------
Last Update Date | 08/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 PINE ST MEDICAL ARTS BLDG
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14701-5384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-487-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 56 82 RUGGLES STREET #1
-----------------------------------------------------
City | DUNKIRK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14048-0056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | 285711
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------