1639589773 NPI number — MRS. KIMBERLY LA'DAWN WATSON CNP

Table of content: MRS. KIMBERLY LA'DAWN WATSON CNP (NPI 1639589773)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639589773 NPI number — MRS. KIMBERLY LA'DAWN WATSON CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON
Provider First Name:
KIMBERLY
Provider Middle Name:
LA'DAWN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MILLER
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
LA'DAWN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639589773
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 BENSON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45406-4406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-241-5638
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2132 E 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45403-1991
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
397-528-6850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2014

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: 363LF0000X , with the licence number:  NP-C F0414012 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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