Provider Demographics
NPI:1386191526
Name:WATERS, AMY (RN)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
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 1:822 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-3342
Mailing Address - Country:US
Mailing Address - Phone:315-236-6329
Mailing Address - Fax:
Practice Address - Street 1:822 FOREST AVE
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-3342
Practice Address - Country:US
Practice Address - Phone:315-236-6329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY687652251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)