Provider Demographics
NPI:1235707605
Name:WATERS, KAYLIE DIONNE (RN, BSN)
Entity Type:Individual
Prefix:
First Name:KAYLIE
Middle Name:DIONNE
Last Name:WATERS
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776982
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6982
Mailing Address - Country:US
Mailing Address - Phone:231-672-2119
Mailing Address - Fax:
Practice Address - Street 1:1310 WISCONSIN ST STE 204
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2472
Practice Address - Country:US
Practice Address - Phone:616-844-4523
Practice Address - Fax:616-844-4758
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704316107363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics