=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982836011
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA LYNN WATTS CPNP-PC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2009
-----------------------------------------------------
Last Update Date | 04/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 747 E COUNTY LINE RD STE G
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46143-1082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-856-7337
-----------------------------------------------------
Fax | 317-856-7363
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 781076
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48278-1076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-528-4800
-----------------------------------------------------
Fax | 317-865-1479
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 71003010A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------