Provider Demographics
NPI:1053160424
Name:WALKER, CHEYENNE LOREN (PTA)
Entity type:Individual
Prefix:
First Name:CHEYENNE
Middle Name:LOREN
Last Name:WALKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 WEBB TOWN RD
Mailing Address - Street 2:
Mailing Address - City:TUNNEL HILL
Mailing Address - State:IL
Mailing Address - Zip Code:62972-3024
Mailing Address - Country:US
Mailing Address - Phone:618-944-0092
Mailing Address - Fax:
Practice Address - Street 1:120 N TOWER RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1929
Practice Address - Country:US
Practice Address - Phone:618-549-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160010127225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant