1699736496 NPI number — WILMA J WATT CRNA

Table of content: WILMA J WATT CRNA (NPI 1699736496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699736496 NPI number — WILMA J WATT CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATT
Provider First Name:
WILMA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VAN DE PERRE
Provider Other First Name:
WILMA
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699736496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6907
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-793-5000
Provider Business Mailing Address Fax Number:
334-615-8419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4370 W MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-793-5000
Provider Business Practice Location Address Fax Number:
334-615-8419
Provider Enumeration Date:
03/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  1051186 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08808065 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5151685 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00096410 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000652462B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1772488 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 301241700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 051515685 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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