Provider Demographics
NPI:1174162572
Name:WATSON, KORAN BIANCA
Entity type:Individual
Prefix:MISS
First Name:KORAN
Middle Name:BIANCA
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 1:21 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4223
Mailing Address - Country:US
Mailing Address - Phone:267-209-3245
Mailing Address - Fax:267-907-8591
Practice Address - Street 1:21 S 11TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4223
Practice Address - Country:US
Practice Address - Phone:267-209-3245
Practice Address - Fax:267-907-8591
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006020133V00000X
PADN0006020133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADN006020OtherPA NURSING BROAD