Provider Demographics
NPI:1700441912
Name:WATERS, LESLI RENAE
Entity Type:Individual
Prefix:
First Name:LESLI
Middle Name:RENAE
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 1:400 S CULBERSON ST APT 7301
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76240-3857
Mailing Address - Country:US
Mailing Address - Phone:940-232-0678
Mailing Address - Fax:
Practice Address - Street 1:400 S CULBERSON ST APT 7301
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76240-3857
Practice Address - Country:US
Practice Address - Phone:940-232-0678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX192121164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse