MEDICARE: CARMEN WATERMAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC1500X	Community Health Registered Nurse	2013021870	MO

General Provider Information

NPI Number	:	1083208516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARMEN WATERMAN

Provider Business Mailing Address
First Line	:	16905 LAUREL RD
Second Line	:
City	:	ELDRIDGE
State	:	MO
Zip	:	65463-8282
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16037 MINNESOTA AVE
Second Line	:
City	:	FORT LEONARD WOOD
State	:	MO
Zip	:	65473-1648
Country	:	US
Telephone Number	:	573-596-0491
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2021
Last Update Date	:	02/26/2021

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