Provider Demographics
NPI:1336705086
Name:WATSON, TANGELA S
Entity type:Individual
Prefix:
First Name:TANGELA
Middle Name:S
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:PO BOX 984
Mailing Address - Street 2:
Mailing Address - City:FAYETTE
Mailing Address - State:MS
Mailing Address - Zip Code:39069-0984
Mailing Address - Country:US
Mailing Address - Phone:601-532-0245
Mailing Address - Fax:
Practice Address - Street 1:706 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2366
Practice Address - Country:US
Practice Address - Phone:601-990-2513
Practice Address - Fax:601-990-2526
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS801415495OtherDRIVER'S LICENSE