Provider Demographics
NPI:1457318826
Name:WATERHOUSE, MARIANNE L (CRNA)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:L
Last Name:WATERHOUSE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 NORMANDY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1725
Mailing Address - Country:US
Mailing Address - Phone:704-384-4239
Mailing Address - Fax:704-384-5636
Practice Address - Street 1:200 HAWTHORNE LANE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-384-4239
Practice Address - Fax:704-384-5636
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC035807367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNAN078Medicaid
NC8050815Medicaid
260885Medicare ID - Type Unspecified
NC8050815Medicaid