Provider Demographics
NPI:1619327970
Name:WATERS, MANDY LYNNE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:LYNNE
Last Name:WATERS
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 ARLINGTON CTR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2883
Mailing Address - Country:US
Mailing Address - Phone:580-272-0025
Mailing Address - Fax:580-272-6659
Practice Address - Street 1:721 BETTER NOW PLZ
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2279
Practice Address - Country:US
Practice Address - Phone:580-272-0025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR 0073536363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK550021ZHJPMedicaid