Provider Demographics
NPI:1992461461
Name:WATSON, KIMBERLY GROHT (FNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:GROHT
Last Name:WATSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 MAIN ST STE 1000
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-4092
Mailing Address - Country:US
Mailing Address - Phone:225-654-1559
Mailing Address - Fax:225-654-6212
Practice Address - Street 1:6550 MAIN ST STE 1000
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4092
Practice Address - Country:US
Practice Address - Phone:225-654-1559
Practice Address - Fax:225-654-6212
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA222087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily