Provider Demographics
NPI:1962744482
Name:WATTS, KENDRA (CPNP)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:WATTS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 SIXTH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3861
Mailing Address - Country:US
Mailing Address - Phone:601-799-4777
Mailing Address - Fax:
Practice Address - Street 1:1016 SIXTH AVE STE C
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3861
Practice Address - Country:US
Practice Address - Phone:601-799-4777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR857309363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics