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General NPI Number Information
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NPI Number | 1699211631
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Entity Type | Individual
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Provider Name | JACQUELYN E VAN WATERS NP-C
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Gender | Female
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Dates
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Enumeration Date | 01/15/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2670 NEW HOLT RD STE C
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City | PADUCAH
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State | KY
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Zip | 42001-7506
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Country | US
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Telephone | 270-575-1010
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Fax | 270-575-1007
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Provider Business Mailing Address
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Address Line | 607 MINTER RD
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City | SYMSONIA
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State | KY
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Zip | 42082-9402
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Country | US
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Telephone | 270-703-9095
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 3011205
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License Number State | KY
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