Provider Demographics
NPI:1104676121
Name:WATERS, LISA LYNN (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:WATERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LYNN
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 871545
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-1545
Mailing Address - Country:US
Mailing Address - Phone:907-376-4534
Mailing Address - Fax:907-376-2348
Practice Address - Street 1:26731 W POINT MACKENZIE RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-8709
Practice Address - Country:US
Practice Address - Phone:907-376-4534
Practice Address - Fax:907-376-4534
Is Sole Proprietor?:No
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK108019163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse