Provider Demographics
NPI:1144862111
Name:WATSON, REAGAN NICOLE
Entity type:Individual
Prefix:
First Name:REAGAN
Middle Name:NICOLE
Last Name:WATSON
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 1:40 PINE FOREST TRAIL
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:AR
Mailing Address - Zip Code:72519
Mailing Address - Country:US
Mailing Address - Phone:417-252-4500
Mailing Address - Fax:
Practice Address - Street 1:40 PINE FOREST TRAIL
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:AR
Practice Address - Zip Code:72519
Practice Address - Country:US
Practice Address - Phone:417-252-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider