Provider Demographics
NPI:1003236522
Name:WATERMAN, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WATERMAN
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 1:7371 LAWRENCE 1232
Mailing Address - Street 2:
Mailing Address - City:ASH GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65604-7187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7371 LAWRENCE 1232
Practice Address - Street 2:
Practice Address - City:ASH GROVE
Practice Address - State:MO
Practice Address - Zip Code:65604-7187
Practice Address - Country:US
Practice Address - Phone:417-942-8212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012018184224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant