Provider Demographics
NPI:1326476318
Name:WALTERS, CHANETTA
Entity Type:Individual
Prefix:
First Name:CHANETTA
Middle Name:
Last Name:WALTERS
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 1:2221 CAMPBELLTON RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-4607
Mailing Address - Country:US
Mailing Address - Phone:678-704-3905
Mailing Address - Fax:
Practice Address - Street 1:2221 CAMPBELLTON RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-4607
Practice Address - Country:US
Practice Address - Phone:678-704-3905
Practice Address - Fax:770-994-9894
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-29
Last Update Date:2013-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO0395881744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management