Despite worldwide advances in urban water security, equitable access to safely managed drinking water remains a challenge in low- and middle-income countries (LMICs). Piped water on premises is widely considered the gold standard for drinking water provision and is expanding rapidly in small and medium urban centres in LMICs. However, intermittency in urban water supply can lead to unreliability and water quality issues, posing a key barrier to equitable water security. Leveraging mixed methods and multiple data sets, this study investigates to what extent urban water security is equitable in a small town in Northern Ethiopia with almost uniform access to piped water services. We demonstrate that, despite widespread access to piped water on premises, there is considerable heterogeneity in household water insecurity. Development of a household water insecurity index considering issues of quality, quantity, and reliability, demonstrated high spatial variability in water security between households connected to the piped water system. Reliability of piped water supply did not equate to high water security in every case, as accessibility of appropriate alternative supplies and storage mediated water security. Urban water planning in LMICs must go beyond the physical expansion of household water connections to consider the implications of spatiality, intermittency of supply, and gendered socio-economic vulnerability to deliver equitable urban water security.