Healthcare Provider Details

I. General information

NPI: 1093164188
Provider Name (Legal Business Name): ANGEL M. WATERS FNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 ANDOVER RD
WESTBROOK ME
04092-3848
US

IV. Provider business mailing address

123 ANDOVED RD
WESTBROOK ME
04092-3848
US

V. Phone/Fax

Practice location:
  • Phone: 207-661-6352
  • Fax:
Mailing address:
  • Phone: 207-661-6352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024173519
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP171026
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN55400
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: