Provider Demographics
NPI:1265033179
Name:WALTON, NAKIESHA
Entity Type:Individual
Prefix:
First Name:NAKIESHA
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 EDGEBROOK DR APT 115
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-1446
Mailing Address - Country:US
Mailing Address - Phone:815-508-7131
Mailing Address - Fax:
Practice Address - Street 1:807 RIDGE DR # 520
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-1385
Practice Address - Country:US
Practice Address - Phone:815-508-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-06
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILW4356-3797-698172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty