Provider Demographics
NPI:1285385005
Name:WATTS, SHANE MARK (APRN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:MARK
Last Name:WATTS
Suffix:
Gender:M
Credentials:APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 LAKELYNN AVE
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40065-7403
Mailing Address - Country:US
Mailing Address - Phone:502-689-9994
Mailing Address - Fax:
Practice Address - Street 1:801 BARRET AVE STE 110
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1732
Practice Address - Country:US
Practice Address - Phone:502-792-0275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3017240363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health