Provider Demographics
NPI:1063477867
Name:WALTON, MARY LOUISE (CNM MSN)
Entity Type:Individual
Prefix:MS
First Name:MARY LOUISE
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:CNM MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MERCADO ST STE 145
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7311
Mailing Address - Country:US
Mailing Address - Phone:970-247-5543
Mailing Address - Fax:970-247-5545
Practice Address - Street 1:1 MERCADO ST STE 145
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7311
Practice Address - Country:US
Practice Address - Phone:970-247-5543
Practice Address - Fax:970-247-5545
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO57247367A00000X
NM409367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01YH34OtherNM BCBS PROVIDER ID
MW0461258OtherFEDERAL CONTROLLED SUBSTANCE
CO07085426Medicaid
NMR6127Medicaid
84-1491843OtherPRACTICE TAX ID
CO8542OtherANMW CERTIFICATION
CO07085426Medicaid