Provider Demographics
NPI:1396006763
Name:WATERS, OPHELIA RENEE (CMA)
Entity Type:Individual
Prefix:MRS
First Name:OPHELIA
Middle Name:RENEE
Last Name:WATERS
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6568 EMMITT ST
Mailing Address - Street 2:
Mailing Address - City:MILLINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38053-8267
Mailing Address - Country:US
Mailing Address - Phone:901-873-3081
Mailing Address - Fax:
Practice Address - Street 1:6568 EMMITT ST
Practice Address - Street 2:
Practice Address - City:MILLINGTON
Practice Address - State:TN
Practice Address - Zip Code:38053-8267
Practice Address - Country:US
Practice Address - Phone:901-873-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide