Provider Demographics
NPI:1770636243
Name:WATERS, TAMMIE C (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:TAMMIE
Middle Name:C
Last Name:WATERS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 MILL ST
Mailing Address - Street 2:
Mailing Address - City:BALDWYN
Mailing Address - State:MS
Mailing Address - Zip Code:38824-2122
Mailing Address - Country:US
Mailing Address - Phone:662-365-3253
Mailing Address - Fax:662-365-3484
Practice Address - Street 1:305 MILL ST
Practice Address - Street 2:
Practice Address - City:BALDWYN
Practice Address - State:MS
Practice Address - Zip Code:38824-2122
Practice Address - Country:US
Practice Address - Phone:662-365-3253
Practice Address - Fax:662-365-3484
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR574929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS32-0073167OtherHEALTHLINK
MS32-0073167OtherBLUE CROSSBLUE SHIELD
MS32-0073167OtherCIGNA
MS32-0073167OtherAETNA
MS03222231Medicaid
MS32-0073167OtherUNITED HEALTHCARE
MS32-0073167OtherBAPTIST
MS32-0073167OtherBLUE CROSSBLUE SHIELD
MSS70987Medicare UPIN