Provider Demographics
NPI:1932663309
Name:WATERS, ELIZABETH ELLEN (IBCLC, RLC, CPPD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ELLEN
Last Name:WATERS
Suffix:
Gender:F
Credentials:IBCLC, RLC, CPPD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:ELLEN
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IBCLC
Mailing Address - Street 1:9326 N TIOGA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-2458
Mailing Address - Country:US
Mailing Address - Phone:541-645-3018
Mailing Address - Fax:503-506-0676
Practice Address - Street 1:7319 N JOHN AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4885
Practice Address - Country:US
Practice Address - Phone:503-755-8328
Practice Address - Fax:503-506-0676
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLC-10196698174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORLC-LC-10196698OtherOREGON HEALTH LICENSING-LACTATION CONSULTANT PROGRAM
VAL-152153OtherINTERNATIONAL BOARD OF LACTATION CONSULTANT EXAMINERS