Provider Demographics
NPI:1770122772
Name:WATERS, WILLIE MAE
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:MAE
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 1:1700 ST LUKES BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-5670
Mailing Address - Country:US
Mailing Address - Phone:484-526-7246
Mailing Address - Fax:866-291-6192
Practice Address - Street 1:1700 ST LUKES BLVD STE 200
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-5670
Practice Address - Country:US
Practice Address - Phone:484-526-7246
Practice Address - Fax:866-291-6192
Is Sole Proprietor?:No
Enumeration Date:2019-12-23
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021320363LA2200X
NJ26NJ01285800363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health