Basic Information
| Provider Information | |||||||||
| NPI: | 1235760166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATTERSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 W 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283584514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102589467 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2511 OLD CORNWALLIS RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277131869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199325700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2020 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5012779 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 14612409 | 05 | NC | MEDICAID |