Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | APN0000006558 | TN |
NPI | 1003055443 |
---|---|
Provider Name | Gwendolyn Watson |
First Address | Southaven, MS 38671-3975 |
Second Address | Memphis, TN 38103-1945 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/02/2009 |
Last Update Date | 09/02/2009 |