Provider Demographics
NPI:1144725151
Name:WATERS, ELLEN KLIGERMAN (CRNP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:KLIGERMAN
Last Name:WATERS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-4160
Mailing Address - Country:US
Mailing Address - Phone:215-430-4000
Mailing Address - Fax:
Practice Address - Street 1:3551 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-4160
Practice Address - Country:US
Practice Address - Phone:215-430-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-30
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP017938363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics