Provider Demographics
NPI:1043852809
Name:WALTERS, HEADLEY JUNIOR RICKY (BSN, RN)
Entity Type:Individual
Prefix:MR
First Name:HEADLEY
Middle Name:JUNIOR RICKY
Last Name:WALTERS
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22018 SW 93RD PL
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1230
Mailing Address - Country:US
Mailing Address - Phone:786-804-8696
Mailing Address - Fax:
Practice Address - Street 1:14400 SW 32ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-6545
Practice Address - Country:US
Practice Address - Phone:305-220-9599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9395952163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice