Provider Demographics
NPI:1164857371
Name:WALWORTH, AMY L (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:WALWORTH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450B WASHINGTON JACKSON RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320-7600
Mailing Address - Country:US
Mailing Address - Phone:937-456-8350
Mailing Address - Fax:937-456-8351
Practice Address - Street 1:450B WASHINGTON JACKSON RD
Practice Address - Street 2:SUITE 105
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320-7600
Practice Address - Country:US
Practice Address - Phone:937-456-8350
Practice Address - Fax:937-456-8351
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14968NP363LF0000X
OHAPRN.CNP.14968363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0098699Medicaid
OHH241440Medicare PIN