Healthcare Provider Details

I. General information

NPI: 1235159385
Provider Name (Legal Business Name): STEPHANIE RENEE WATERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 BELVEDERE ST
CARLISLE PA
17013
US

IV. Provider business mailing address

804 BELVEDERE ST
CARLISLE PA
17013-4001
US

V. Phone/Fax

Practice location:
  • Phone: 717-243-1653
  • Fax: 717-243-6708
Mailing address:
  • Phone: 717-243-1653
  • Fax: 717-243-6708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number18655
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD437871
License Number StatePA

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: