Healthcare Provider Details

I. General information

NPI: 1285950170
Provider Name (Legal Business Name): DEBRA KAY WATERS MLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2010
Last Update Date: 04/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLACK COAL RD. BLDG. 29
FT. WASHAKIE WY
82514
US

IV. Provider business mailing address

29 BLACK COAL RD.
FT. WASHAKIE WY
82514
US

V. Phone/Fax

Practice location:
  • Phone: 307-332-7672
  • Fax:
Mailing address:
  • Phone: 307-332-7672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number21259
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: