Provider Demographics
NPI:1083665459
Name:WATERS-HOLLINGSWORTH, CARLENE D (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CARLENE
Middle Name:D
Last Name:WATERS-HOLLINGSWORTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W COLONIAL DR STE 495
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3436
Mailing Address - Country:US
Mailing Address - Phone:407-293-5944
Mailing Address - Fax:407-293-7355
Practice Address - Street 1:10000 W COLONIAL DR STE 495
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3436
Practice Address - Country:US
Practice Address - Phone:407-293-5944
Practice Address - Fax:407-293-7355
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052039363A00000X
FLPA9104786363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLBO414WMedicare PIN
Q46055Medicare UPIN
FLBO414XMedicare PIN