Provider Demographics
NPI:1649638776
Name:WATERS, ANTAY LANE (DNP, APRN, CNM, WHNP)
Entity type:Individual
Prefix:
First Name:ANTAY
Middle Name:LANE
Last Name:WATERS
Suffix:
Gender:F
Credentials:DNP, APRN, CNM, WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 GROVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-3811
Mailing Address - Country:US
Mailing Address - Phone:682-500-0928
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-702-3595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX808428163WR0006X
TXAP130426363LW0102X
TX1030115367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health