Provider Demographics
NPI:1073816617
Name:WATSON, CHARLENE DENISE
Entity type:Individual
Prefix:
First Name:CHARLENE
Middle Name:DENISE
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 1:4118 LESLIE LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-6247
Mailing Address - Country:US
Mailing Address - Phone:850-257-5176
Mailing Address - Fax:850-257-5176
Practice Address - Street 1:4118 LESLIE LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32404-6247
Practice Address - Country:US
Practice Address - Phone:850-257-5176
Practice Address - Fax:850-257-5176
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-20
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
FL374P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL683204198Other683204196