1184273336 NPI number — KATIE KNIGHT WATERS

Table of content: KATIE KNIGHT WATERS (NPI 1184273336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184273336 NPI number — KATIE KNIGHT WATERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS
Provider First Name:
KATIE
Provider Middle Name:
KNIGHT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184273336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7751 BELFORT PKWY STE 350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-6951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-363-7453
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5742 BOOTH RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-5982
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-739-7779
Provider Business Practice Location Address Fax Number:
904-739-7771
Provider Enumeration Date:
09/10/2019

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: 363A00000X , with the licence number:  PA9112252 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 104285300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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