Basic Information
| Provider Information | |||||||||
| NPI: | 1295242535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | LEANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 E SPAULDING AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192969000 | ||||||||
| FaxNumber: | 7192969001 | ||||||||
| Practice Location | |||||||||
| Address1: | 3530 E SPAULDING AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810082209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192969000 | ||||||||
| FaxNumber: | 7192969001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2018 | ||||||||
| LastUpdateDate: | 01/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | SA0001084 | CO | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.