Provider Demographics
NPI:1316559966
Name:WALKER, ROYEISHA DESHAWN
Entity Type:Individual
Prefix:
First Name:ROYEISHA
Middle Name:DESHAWN
Last Name:WALKER
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 1:3635 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-5803
Mailing Address - Country:US
Mailing Address - Phone:323-910-7641
Mailing Address - Fax:
Practice Address - Street 1:3635 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-5803
Practice Address - Country:US
Practice Address - Phone:323-910-7641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS800890072OtherDRIVERS LICENSE