Provider Demographics
NPI:1548302607
Name:WATERS, BEVERLY ANN (CRNP)
Entity type:Individual
Prefix:MRS
First Name:BEVERLY
Middle Name:ANN
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 1:1526 WYNSAM ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-1628
Mailing Address - Country:US
Mailing Address - Phone:215-424-7033
Mailing Address - Fax:
Practice Address - Street 1:ST. CHRISTOPHER'S HOSPITAL FOR CHILDREN PRIMARY PEDIATR
Practice Address - Street 2:ERIE AVENUE AT FRONT STREET
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134
Practice Address - Country:US
Practice Address - Phone:215-427-5936
Practice Address - Fax:215-427-6501
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP001807D363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01469539Medicaid
PAS94145Medicare UPIN