Provider Demographics
NPI:1225197254
Name:WATERS, FELICIA A (RN)
Entity Type:Individual
Prefix:MRS
First Name:FELICIA
Middle Name:A
Last Name:WATERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 BIG BEND RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53189-7649
Mailing Address - Country:US
Mailing Address - Phone:262-548-9372
Mailing Address - Fax:
Practice Address - Street 1:1430 BIG BEND RD UNIT A
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53189-7649
Practice Address - Country:US
Practice Address - Phone:262-548-9372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35013800Medicaid