Provider Demographics
NPI:1114686540
Name:WALTON, NICOLE LESLIE (DNP)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LESLIE
Last Name:WALTON
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 CIVIC CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5127
Mailing Address - Country:US
Mailing Address - Phone:215-615-5252
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD FL 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5127
Practice Address - Country:US
Practice Address - Phone:215-615-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP024255363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care