Basic Information
| Provider Information | |||||||||
| NPI: | 1467882126 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PT, DPT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 EASTGATE MALL STE 105 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1858775926 | ||||||||
| FaxNumber: | 8503988482 | ||||||||
| Practice Location | |||||||||
| Address1: | 88 E BONITA RD STE C | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919103057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192300855 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2013 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | PT32013 | FL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 225100000X | PT32013 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.