Provider Demographics
NPI:1891100947
Name:WATERS, KORI (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KORI
Middle Name:
Last Name:WATERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2837 OLD BELLEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ST MATTHEWS
Mailing Address - State:SC
Mailing Address - Zip Code:29135-9010
Mailing Address - Country:US
Mailing Address - Phone:803-874-2037
Mailing Address - Fax:
Practice Address - Street 1:2837 OLD BELLEVILLE RD
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:SC
Practice Address - Zip Code:29135-9010
Practice Address - Country:US
Practice Address - Phone:803-874-2037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP42236164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse