Provider Demographics
NPI:1558553495
Name:WATERS, SHELLY NOLEN (FNPC)
Entity Type:Individual
Prefix:MS
First Name:SHELLY
Middle Name:NOLEN
Last Name:WATERS
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:MRS
Other - First Name:SHELLY
Other - Middle Name:NOLEN
Other - Last Name:THERRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNPC
Mailing Address - Street 1:100 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566
Mailing Address - Country:US
Mailing Address - Phone:979-299-2870
Mailing Address - Fax:979-299-2878
Practice Address - Street 1:668 W BRAZOS AVE
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:TX
Practice Address - Zip Code:77486-2616
Practice Address - Country:US
Practice Address - Phone:979-345-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX604695363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily