Provider Demographics
NPI:1447659560
Name:WALTERS, NOLA
Entity type:Individual
Prefix:
First Name:NOLA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253-51147 DRIVE
Mailing Address - Street 2:QUEENS
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:253-51147 DRIVE
Practice Address - Street 2:QUEENS
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422
Practice Address - Country:US
Practice Address - Phone:917-705-0094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY630715-1172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker