Provider Demographics
NPI:1043458912
Name:WALTER, CHARLOTTE ANN
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ANN
Last Name:WALTER
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 1:5636 GLACIER HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801-9508
Mailing Address - Country:US
Mailing Address - Phone:907-586-6838
Mailing Address - Fax:907-586-8114
Practice Address - Street 1:5636 GLACIER HWY
Practice Address - Street 2:STE 100
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-9508
Practice Address - Country:US
Practice Address - Phone:907-586-6838
Practice Address - Fax:907-586-8114
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCMG974171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM0110Medicaid