Provider Demographics
NPI:1073630745
Name:WATERWORTH, LINDA B (ANP)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:B
Last Name:WATERWORTH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 JOHNSTON WILLIS DR
Mailing Address - Street 2:SUITE 4500
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4730
Mailing Address - Country:US
Mailing Address - Phone:804-320-1355
Mailing Address - Fax:804-560-3531
Practice Address - Street 1:1401 JOHNSTON WILLIS DR
Practice Address - Street 2:SUITE 4500
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-4730
Practice Address - Country:US
Practice Address - Phone:804-320-1355
Practice Address - Fax:804-560-3531
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001078920363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001078920OtherSTATE LISCENSE