Provider Demographics
NPI:1326263583
Name:WALKER, MARY (ATC,LAT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:ATC,LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2191 HIGH RIGGER PL
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4517
Mailing Address - Country:US
Mailing Address - Phone:904-261-9875
Mailing Address - Fax:
Practice Address - Street 1:2191 HIGH RIGGER PL
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4517
Practice Address - Country:US
Practice Address - Phone:904-261-9875
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer