Provider Demographics
NPI:1316984230
Name:WATERS, LESA FERRELL (FNP)
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:FERRELL
Last Name:WATERS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1649
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-1649
Mailing Address - Country:US
Mailing Address - Phone:601-399-6158
Mailing Address - Fax:601-399-6281
Practice Address - Street 1:109 NORTH FRONT ST.
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39477-0001
Practice Address - Country:US
Practice Address - Phone:601-426-7603
Practice Address - Fax:601-426-1087
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR781266163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIR781266OtherBOARD OF NURSING LICENSE