Basic Information
| Provider Information | |||||||||
| NPI: | 1194996892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | SHELLEY | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | APRN FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175562727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 MERCY WAY | ||||||||
| Address2: | |||||||||
| City: | JOPLIN | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648044524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175562727 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 53-74929-072 | KS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 2000163262 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 200549940B | 05 | KS | MEDICAID | 53-74929-072 | 01 | KS | KANSAS LICENSE | OTHER |