Provider Demographics
NPI:1063091205
Name:WATSON, MONIQUE M
Entity type:Individual
Prefix:
First Name:MONIQUE
Middle Name:M
Last Name:WATSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-3307
Mailing Address - Country:US
Mailing Address - Phone:901-267-4008
Mailing Address - Fax:901-267-4099
Practice Address - Street 1:4041 KNIGHT ARNOLD RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-2128
Practice Address - Country:US
Practice Address - Phone:901-505-0690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2025-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30880363LP0808X
TN135847163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health