Basic Information
| Provider Information | |||||||||
| NPI: | 1033844865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2016 E DUKE AVE | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740758290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184483636 | ||||||||
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| Practice Location | |||||||||
| Address1: | 19600 E ROSS ST | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744640545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5392341000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2022 | ||||||||
| LastUpdateDate: | 07/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 206172 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.