Provider Demographics
NPI:1619642881
Name:WATERS, KATELYN R (FNP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:R
Last Name:WATERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-293-7330
Practice Address - Street 1:3 RICHLAND MEDICAL PARK DR STE 310
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6862
Practice Address - Country:US
Practice Address - Phone:803-434-8324
Practice Address - Fax:803-434-8326
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25183363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP7758Medicaid