Healthcare Provider Details

I. General information

NPI: 1588492722
Provider Name (Legal Business Name): LYLA DAE WATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 HAVEN DR
DOTHAN AL
36301-2907
US

IV. Provider business mailing address

213 PINERIDGE RD # AL
TAYLOR AL
36301-9197
US

V. Phone/Fax

Practice location:
  • Phone: 334-709-4024
  • Fax:
Mailing address:
  • Phone: 334-547-1408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: