Provider Demographics
NPI:1992745905
Name:WATTS, TAMMY G (ANP)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:G
Last Name:WATTS
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3710 LANDMARK DR
Mailing Address - Street 2:STE 114
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-4034
Mailing Address - Country:US
Mailing Address - Phone:803-851-5966
Mailing Address - Fax:803-828-4618
Practice Address - Street 1:3710 LANDMARK DR
Practice Address - Street 2:STE 114
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4034
Practice Address - Country:US
Practice Address - Phone:803-788-5916
Practice Address - Fax:803-788-9564
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC455363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0642Medicaid
SCNP0642Medicaid