Provider Demographics
NPI:1053840959
Name:WALTERS, ROBERTA ANNE (APRN)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ANNE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5856
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31107-0856
Mailing Address - Country:US
Mailing Address - Phone:888-772-0076
Mailing Address - Fax:770-751-8014
Practice Address - Street 1:704 BREEDLOVE DR STE A
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2054
Practice Address - Country:US
Practice Address - Phone:888-772-0076
Practice Address - Fax:770-751-8014
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN190448363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily