Provider Demographics
NPI:1225461569
Name:WALKER, MAXWELL (RD, LD)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:
Last Name:WALKER
Suffix:
Gender:M
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 W HOMER ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-1280
Mailing Address - Country:US
Mailing Address - Phone:888-785-7370
Mailing Address - Fax:
Practice Address - Street 1:818 SUGAR VALLEY CT
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-7474
Practice Address - Country:US
Practice Address - Phone:719-694-4352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013028579133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered