Provider Demographics
NPI:1871115170
Name:WALTON, KRISTEN RAE (OD)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RAE
Last Name:WALTON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:WALTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:3101 W 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-3162
Mailing Address - Country:US
Mailing Address - Phone:605-371-7000
Mailing Address - Fax:605-371-7199
Practice Address - Street 1:4909 S 118TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2213
Practice Address - Country:US
Practice Address - Phone:402-397-2010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1547152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1547OtherNEBRASKA LICENSE