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General NPI Number Information
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NPI Number | 1770122772
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Entity Type | Individual
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Provider Name | WILLIE MAE WATERS
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Gender | Female
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Dates
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Enumeration Date | 12/23/2019
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Last Update Date | 02/16/2023
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Provider Practice Location Address
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Address Line | 1700 ST LUKES BLVD STE 200
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City | EASTON
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State | PA
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Zip | 18045-5670
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Country | US
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Telephone | 484-526-7246
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Fax | 866-291-6192
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Provider Business Mailing Address
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Address Line | 1700 ST LUKES BLVD STE 200
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City | EASTON
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State | PA
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Zip | 18045-5670
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Country | US
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Telephone | 484-526-7246
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Fax | 866-291-6192
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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 | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | SP021320
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 26NJ01285800
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License Number State | NJ
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