MEDICARE: MRS. WANDA BERNADETTE WATERS BSN, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN 302116	OH

General Provider Information

NPI Number	:	1255541348
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WANDA BERNADETTE WATERS BSN, RN

Provider Business Mailing Address
First Line	:	1122 BROAD AVENUE NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-9705
Country	:	US
Telephone Number	:	330-704-9206
Fax Number	:

Provider Business Practice Location Address
First Line	:	1122 BROAD AVE NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44708-4215
Country	:	US
Telephone Number	:	330-704-9206
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	02/17/2015

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