Provider Demographics
NPI:1891037156
Name:WATERS, DEANNA L (LMT)
Entity Type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:L
Last Name:WATERS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 LEON RD
Mailing Address - Street 2:3321
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-8682
Mailing Address - Country:US
Mailing Address - Phone:904-413-2692
Mailing Address - Fax:
Practice Address - Street 1:1755 LEON RD
Practice Address - Street 2:3321
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-8682
Practice Address - Country:US
Practice Address - Phone:904-413-2692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL67010225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL67010OtherLMT