Provider Demographics
NPI:1407416308
Name:WATERS, NICOLE POYTHRESS (DO, PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:POYTHRESS
Last Name:WATERS
Suffix:
Gender:F
Credentials:DO, PHD
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 155
Mailing Address - Street 2:
Mailing Address - City:CHRISTOPHER
Mailing Address - State:IL
Mailing Address - Zip Code:62822-0155
Mailing Address - Country:US
Mailing Address - Phone:618-724-2401
Mailing Address - Fax:
Practice Address - Street 1:7211 US 45 S
Practice Address - Street 2:
Practice Address - City:CARRIER MILLS
Practice Address - State:IL
Practice Address - Zip Code:62917-1305
Practice Address - Country:US
Practice Address - Phone:618-294-8247
Practice Address - Fax:618-294-8247
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036157809207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine