1700081403 NPI number — MRS. DARA ANN WATERS PT

Table of content: MRS. DARA ANN WATERS PT (NPI 1700081403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700081403 NPI number — MRS. DARA ANN WATERS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS
Provider First Name:
DARA
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OGLESBY
Provider Other First Name:
DARA
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700081403
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4903 COUNTY ROAD P39
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT CALHOUN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68023-5077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-660-7289
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68059-6845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-253-3079
Provider Business Practice Location Address Fax Number:
402-253-2631
Provider Enumeration Date:
06/20/2007

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: 225100000X , with the licence number:  2561 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2561 . This is a "STATE LICENSE" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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