Provider Demographics
NPI:1295028959
Name:WATERS, KATHLEEN ANNE (APRN)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANNE
Last Name:WATERS
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 N CEDAR ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-6453
Mailing Address - Country:US
Mailing Address - Phone:843-821-2480
Mailing Address - Fax:843-875-3149
Practice Address - Street 1:204 N CEDAR ST STE 100
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6453
Practice Address - Country:US
Practice Address - Phone:843-821-2480
Practice Address - Fax:843-875-3149
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4447364SP0809X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult