Provider Demographics
NPI:1215625181
Name:WATSON, ALICIA LAVETTE (NP)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:LAVETTE
Last Name:WATSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2843 MANDY CT
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-4187
Mailing Address - Country:US
Mailing Address - Phone:229-375-4886
Mailing Address - Fax:
Practice Address - Street 1:3651 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6426
Practice Address - Country:US
Practice Address - Phone:706-651-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN259656363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner