Provider Demographics
NPI:1316594492
Name:WALTER, KELLY ANNE (TEACHER)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:WALTER
Suffix:
Gender:F
Credentials:TEACHER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 CRYSTAL RUN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-7010
Mailing Address - Country:US
Mailing Address - Phone:845-692-4391
Mailing Address - Fax:
Practice Address - Street 1:75 CRYSTAL RUN RD STE 201
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-7010
Practice Address - Country:US
Practice Address - Phone:845-692-4391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist