Provider Demographics
NPI:1285869578
Name:WATSON, DEITRA MECHELLE (MSN, APRN-BC)
Entity type:Individual
Prefix:MRS
First Name:DEITRA
Middle Name:MECHELLE
Last Name:WATSON
Suffix:
Gender:F
Credentials:MSN, APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:865-522-8603
Mailing Address - Fax:
Practice Address - Street 1:1501 SUMTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2829
Practice Address - Country:US
Practice Address - Phone:803-296-3726
Practice Address - Fax:803-296-3460
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3842363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1528Medicaid