Provider Demographics
NPI:1366264624
Name:WATERS, ROENA ANGELA (ADULT FAMILY HOME)
Entity type:Individual
Prefix:
First Name:ROENA
Middle Name:ANGELA
Last Name:WATERS
Suffix:
Gender:F
Credentials:ADULT FAMILY HOME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 63RD AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1709
Mailing Address - Country:US
Mailing Address - Phone:262-351-5955
Mailing Address - Fax:262-222-2399
Practice Address - Street 1:4910 63RD AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-1709
Practice Address - Country:US
Practice Address - Phone:262-351-5955
Practice Address - Fax:262-222-2399
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0019382251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health