Provider Demographics
NPI:1316582687
Name:WALTERS, ALEXANDRA NICOLE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2135
Mailing Address - Country:US
Mailing Address - Phone:708-346-5562
Mailing Address - Fax:708-346-2059
Practice Address - Street 1:3545 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2135
Practice Address - Country:US
Practice Address - Phone:708-346-5562
Practice Address - Fax:708-346-2059
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209020072363L00000X
IL020072363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner