MEDICARE: SHANE MARK WATTS APRN, PMHNP-BC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	3017240	KY

General Provider Information

NPI Number	:	1285385005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE MARK WATTS APRN, PMHNP-BC

Provider Business Mailing Address
First Line	:	130 LAKELYNN AVE
Second Line	:
City	:	SHELBYVILLE
State	:	KY
Zip	:	40065-7403
Country	:	US
Telephone Number	:	502-689-9994
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 BARRET AVE STE 110
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-1732
Country	:	US
Telephone Number	:	502-792-0275
Fax Number	:

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

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	10/30/2025

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