Provider Demographics
NPI:1053902858
Name:WALTERS, ALTHEA JOANNE (APRN)
Entity type:Individual
Prefix:
First Name:ALTHEA
Middle Name:JOANNE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2066
Mailing Address - Street 2:
Mailing Address - City:LECANTO
Mailing Address - State:FL
Mailing Address - Zip Code:34460-2066
Mailing Address - Country:US
Mailing Address - Phone:352-563-0931
Mailing Address - Fax:
Practice Address - Street 1:11371 N WILLIAMS ST STE 4
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-8362
Practice Address - Country:US
Practice Address - Phone:352-465-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11011355363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110428000Medicaid