Provider Demographics
NPI:1285950170
Name:WATERS, DEBRA KAY (MLT)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:KAY
Last Name:WATERS
Suffix:
Gender:F
Credentials:MLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BLACK COAL RD.
Mailing Address - Street 2:
Mailing Address - City:FT. WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514
Mailing Address - Country:US
Mailing Address - Phone:307-332-7672
Mailing Address - Fax:
Practice Address - Street 1:BLACK COAL RD. BLDG. 29
Practice Address - Street 2:
Practice Address - City:FT. WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-332-7672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21259246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN04121413OtherASCP