Provider Demographics
NPI:1558087544
Name:WATERS, DEANGELO
Entity Type:Individual
Prefix:
First Name:DEANGELO
Middle Name:
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32225 SHAW RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-8851
Mailing Address - Country:US
Mailing Address - Phone:740-270-2963
Mailing Address - Fax:
Practice Address - Street 1:444 HENRIETTA AVE
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-1634
Practice Address - Country:US
Practice Address - Phone:740-270-2963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide