MEDICARE: KELLY TYLA JORDAN' WATTERS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner

General Provider Information

NPI Number	:	1184984007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY TYLA JORDAN' WATTERS

Provider Business Mailing Address
First Line	:	6551 MCCARRAN ST APT 2029
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89086-1442
Country	:	US
Telephone Number	:	818-614-7658
Fax Number	:

Provider Business Practice Location Address
First Line	:	6551 MCCARRAN ST APT 2029
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89086-1442
Country	:	US
Telephone Number	:	818-614-7658
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2012
Last Update Date	:	05/25/2012

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