Healthcare Provider Details

I. General information

NPI: 1700200656
Provider Name (Legal Business Name): MRS. SARA MARIE WATERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2014
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 NEW GLENDALE RD
ELIZABETHTOWN KY
42701-1023
US

IV. Provider business mailing address

3131 FAIRGROUNDS RD
BRANDENBURG KY
40108-9741
US

V. Phone/Fax

Practice location:
  • Phone: 270-769-1601
  • Fax: 270-982-0829
Mailing address:
  • Phone: 270-668-8349
  • Fax: 270-982-0829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number000076961
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: