Provider Demographics
NPI:1306860697
Name:WALTERS, DORTHIA S (CFNP)
Entity Type:Individual
Prefix:
First Name:DORTHIA
Middle Name:S
Last Name:WALTERS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:HOULKA
Mailing Address - State:MS
Mailing Address - Zip Code:38850-0187
Mailing Address - Country:US
Mailing Address - Phone:662-568-3316
Mailing Address - Fax:662-568-3360
Practice Address - Street 1:106 WALKER ST
Practice Address - Street 2:
Practice Address - City:HOULKA
Practice Address - State:MS
Practice Address - Zip Code:38850-9453
Practice Address - Country:US
Practice Address - Phone:662-568-3316
Practice Address - Fax:662-568-3360
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR573388363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07770365Medicaid
MS07770365Medicaid