Provider Demographics
NPI:1063986974
Name:WATSON, KELLI NICHOALE
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:NICHOALE
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SLATON DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:TX
Mailing Address - Zip Code:76230-4034
Mailing Address - Country:US
Mailing Address - Phone:940-577-2524
Mailing Address - Fax:
Practice Address - Street 1:107 SLATON DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:TX
Practice Address - Zip Code:76230-4034
Practice Address - Country:US
Practice Address - Phone:940-577-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX344782164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse