Provider Demographics
NPI:1639312861
Name:WATERS, KIM (LPN)
Entity type:Individual
Prefix:
First Name:KIM
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 1:2 ROBERT C KERI CT
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-2012
Mailing Address - Country:US
Mailing Address - Phone:800-950-6066
Mailing Address - Fax:
Practice Address - Street 1:2 ROBERT C KERI CT
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-2012
Practice Address - Country:US
Practice Address - Phone:800-950-6066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NP06138700164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse