Provider Demographics
NPI:1942848643
Name:WATERS, TAMARA LYNETTE
Entity Type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:LYNETTE
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:494 MARSH POINTE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7025
Mailing Address - Country:US
Mailing Address - Phone:803-319-0623
Mailing Address - Fax:
Practice Address - Street 1:10050 TWO NOTCH RD STE 7
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4302
Practice Address - Country:US
Practice Address - Phone:803-851-3353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC713621744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management