Provider Demographics
NPI:1134463805
Name:WAITS, DONNIE R (LPN, PDN, AS)
Entity Type:Individual
Prefix:MR
First Name:DONNIE
Middle Name:R
Last Name:WAITS
Suffix:
Gender:M
Credentials:LPN, PDN, AS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 BEATTIE AVE
Mailing Address - Street 2:APT 4
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5646
Mailing Address - Country:US
Mailing Address - Phone:585-735-5202
Mailing Address - Fax:
Practice Address - Street 1:269 BEATTIE AVE
Practice Address - Street 2:APT 4
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5646
Practice Address - Country:US
Practice Address - Phone:585-735-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310806164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03522227Medicaid