Basic Information
| Provider Information | |||||||||
| NPI: | 1780802645 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | THRESA | ||||||||
| MiddleName: | KAYE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | THRESA | ||||||||
| OtherMiddleName: | KAYE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 965 RIDGE LAKE BLVD STE 103 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381209446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012273255 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 N STATE ST | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392022000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017146411 | ||||||||
| FaxNumber: | 6017146421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2007 | ||||||||
| LastUpdateDate: | 03/12/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R652253 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.