Provider Demographics
NPI:1326502782
Name:WATERS, ELIZABETH IVY
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:IVY
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2428 BRYAN GLEN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-4734
Mailing Address - Country:US
Mailing Address - Phone:940-782-6305
Mailing Address - Fax:
Practice Address - Street 1:2200 HICKORY ST
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79601-2345
Practice Address - Country:US
Practice Address - Phone:940-782-6305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program