Provider Demographics
NPI:1962107748
Name:WATTS, AGATHA REBECCA
Entity type:Individual
Prefix:
First Name:AGATHA
Middle Name:REBECCA
Last Name:WATTS
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 1:1600 W LANE AVE UNIT 334
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-3963
Mailing Address - Country:US
Mailing Address - Phone:939-267-8641
Mailing Address - Fax:
Practice Address - Street 1:1600 W LANE AVE UNIT 334
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3963
Practice Address - Country:US
Practice Address - Phone:939-267-8641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant