1134264302 NPI number — AMY ELIZABETH WATERS MS, RD, IBCLC

Table of content: AMY ELIZABETH WATERS MS, RD, IBCLC (NPI 1134264302)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134264302 NPI number — AMY ELIZABETH WATERS MS, RD, IBCLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS
Provider First Name:
AMY
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, RD, IBCLC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WATERS
Provider Other First Name:
BETSY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS, RD, IBCLC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1134264302
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 PINE ROOT BRANCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAKERSVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28705-7418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-688-3631
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1233 SOUTHWEST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-6596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-979-3200
Provider Business Practice Location Address Fax Number:
423-688-3261
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  EXEMPT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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