Provider Demographics
NPI:1699736496
Name:WATT, WILMA J (CRNA)
Entity type:Individual
Prefix:
First Name:WILMA
Middle Name:J
Last Name:WATT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:WILMA
Other - Middle Name:J
Other - Last Name:VAN DE PERRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 6907
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302
Mailing Address - Country:US
Mailing Address - Phone:334-793-5000
Mailing Address - Fax:334-615-8419
Practice Address - Street 1:4370 W MAIN STREET
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305
Practice Address - Country:US
Practice Address - Phone:334-793-5000
Practice Address - Fax:334-615-8419
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1051186367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08808065Medicaid
AL5151685OtherBLUE CROSS BLUE SHIELD
P00096410OtherRR MEDICARE
GA000652462BMedicaid
LA1772488Medicaid
FL301241700Medicaid
AL051515685Medicaid