Provider Demographics
NPI:1447824552
Name:WATTS, KIMBERLY
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:WATTS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 W MALCOLM X ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48915-1008
Mailing Address - Country:US
Mailing Address - Phone:517-490-4086
Mailing Address - Fax:
Practice Address - Street 1:1517 W MALCOLM X ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48915-1008
Practice Address - Country:US
Practice Address - Phone:517-490-4086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FMW320469139249OtherDRIVER LICENCE