Provider Demographics
NPI:1417987561
Name:WATERS, POLLY ANN (RNFA, FNP-C)
Entity Type:Individual
Prefix:MS
First Name:POLLY
Middle Name:ANN
Last Name:WATERS
Suffix:
Gender:F
Credentials:RNFA, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9301 N. CENTRAL EXWPY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-0805
Mailing Address - Country:US
Mailing Address - Phone:214-220-2468
Mailing Address - Fax:214-397-1551
Practice Address - Street 1:9301 N CENTRAL EXPY
Practice Address - Street 2:SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0806
Practice Address - Country:US
Practice Address - Phone:214-220-2468
Practice Address - Fax:214-397-1551
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX646178363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G2281Medicare ID - Type Unspecified
TXQ09599Medicare UPIN