Provider Demographics
NPI:1033689484
Name:WALTON, JUDY A
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:WALTON
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 1:2625 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-2204
Mailing Address - Country:US
Mailing Address - Phone:409-833-2625
Mailing Address - Fax:
Practice Address - Street 1:2625 LAUREL ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-2204
Practice Address - Country:US
Practice Address - Phone:409-835-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138595363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAPI138595OtherAPRN LICENSE NUMBER
TXAPI138595Medicaid
TX27411OtherTBON RX AUTHORIZATION #
TX803630OtherTXBON RN LICENSE NUMBER