Healthcare Provider Details

I. General information

NPI: 1235136375
Provider Name (Legal Business Name): AMBER LYNN WATERS LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 NW 48TH BLVD
GAINESVILLE FL
32607-2206
US

IV. Provider business mailing address

369 NW 48TH BLVD
GAINESVILLE FL
32607-2206
US

V. Phone/Fax

Practice location:
  • Phone: 352-219-5700
  • Fax:
Mailing address:
  • Phone: 352-219-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA0020406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: