Healthcare Provider Details

I. General information

NPI: 1881240273
Provider Name (Legal Business Name): MARILYN LEANN WATERS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2019
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 MANATEE AVE W
BRADENTON FL
34209-3816
US

IV. Provider business mailing address

367 S. GULPH RD ATTN: IPM CREDENTIALING
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 941-745-5999
  • Fax: 941-745-3555
Mailing address:
  • Phone: 941-745-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11003655
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: