MEDICARE: MRS. KRISTEN ELLAJANE WATERS R.N.

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	192573	CO

General Provider Information

NPI Number	:	1861729394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTEN ELLAJANE WATERS R.N.

Provider Business Mailing Address
First Line	:	17570 CARIBOU DR E
Second Line	:
City	:	MONUMENT
State	:	CO
Zip	:	80132-7409
Country	:	US
Telephone Number	:	719-578-3242
Fax Number	:

Provider Business Practice Location Address
First Line	:	1675 GARDEN OF THE GODS RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-9444
Country	:	US
Telephone Number	:	719-578-3242
Fax Number	:

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

Provider Enumeration Date	:	11/04/2009
Last Update Date	:	11/08/2013

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