Provider Demographics
NPI:1588492722
Name:WATERS, LYLA DAE
Entity type:Individual
Prefix:
First Name:LYLA
Middle Name:DAE
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 PINERIDGE RD # AL
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:AL
Mailing Address - Zip Code:36301-9197
Mailing Address - Country:US
Mailing Address - Phone:334-547-1408
Mailing Address - Fax:
Practice Address - Street 1:112 HAVEN DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2907
Practice Address - Country:US
Practice Address - Phone:334-709-4024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program