Provider Demographics
NPI:1215924923
Name:WATTERS, CARRIE LEANN (OD)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:LEANN
Last Name:WATTERS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2539 MARVIN RD NE SUITE B
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516
Mailing Address - Country:US
Mailing Address - Phone:360-459-3333
Mailing Address - Fax:360-459-2724
Practice Address - Street 1:2539 MARVIN RD. NE SUITE B
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516
Practice Address - Country:US
Practice Address - Phone:360-459-3333
Practice Address - Fax:360-459-2724
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003744152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028256Medicaid
OR028256Medicaid
ORV09571Medicare UPIN
OR410014157Medicare PIN
0648670001Medicare NSC
R134845Medicare PIN
OR0648670001Medicare NSC