Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175L00000X | Homeopath | LMT 17282 | OR |
NPI | 1407138746 |
---|---|
Provider Name | Ms. Autumn Lyn Waters |
First Address | Salem, OR 97301-4729 |
Second Address | Salem, OR 97301-4729 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/09/2011 |
Last Update Date | 13/09/2011 |