Provider Demographics
NPI:1629096847
Name:WATERS, SUZANNE (NP)
Entity Type:Individual
Prefix:MS
First Name:SUZANNE
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LEE ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22908-0001
Mailing Address - Country:US
Mailing Address - Phone:434-982-1070
Mailing Address - Fax:434-982-0283
Practice Address - Street 1:LEE ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22908-0001
Practice Address - Country:US
Practice Address - Phone:434-982-1070
Practice Address - Fax:434-982-0283
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY275851363LF0000X
VA0024168335363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04367679Medicaid
NY04367679Medicaid