Provider Demographics
NPI:1013346733
Name:WATERMAN, MELISSA ANN (RN, CRNA)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANN
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7751 COUGHRAN RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78064-4435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234-4504
Practice Address - Country:US
Practice Address - Phone:570-574-1992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR179446163W00000X
NJ26NR12899400163W00000X
NY624304163W00000X
NC215605163W00000X
PARN564419163W00000X
TX825970163W00000X, 367500000X
TXAP125194367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse