Provider Demographics
NPI:1205375045
Name:WALKER, WANIDA (ARNP)
Entity Type:Individual
Prefix:
First Name:WANIDA
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 E KENNEDY BLVD
Mailing Address - Street 2:SPECIALTY CARE CLINIC
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-3511
Mailing Address - Country:US
Mailing Address - Phone:813-307-8064
Mailing Address - Fax:813-272-7116
Practice Address - Street 1:1105 E KENNEDY BLVD
Practice Address - Street 2:SPECIALTY CARE CLINIC
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-3511
Practice Address - Country:US
Practice Address - Phone:813-307-8064
Practice Address - Fax:813-272-7116
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-13
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9199983363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020124600Medicaid