Provider Demographics
NPI:1770732844
Name:WATERMAN, JEANNINE RENEE (ARNP)
Entity type:Individual
Prefix:
First Name:JEANNINE
Middle Name:RENEE
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 NORTH CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-254-4210
Mailing Address - Fax:386-254-4212
Practice Address - Street 1:303 NORTH CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-4210
Practice Address - Fax:386-254-4212
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2796752363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000400700Medicaid
FLARNP2796752OtherMEDICAL LICENSE
FL000400700Medicaid