Provider Demographics
NPI:1548742265
Name:WATERS, PATRICE VERNETTA
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:VERNETTA
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:PATRICE
Other - Middle Name:VERNETTA
Other - Last Name:MAYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5406 MERLE HAY RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5406 MERLE HAY RD
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1209
Practice Address - Country:US
Practice Address - Phone:515-737-8750
Practice Address - Fax:515-727-8757
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist