Provider Demographics
NPI:1346891132
Name:WALTON, MIKALA (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MIKALA
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 KENMORE DR
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:ME
Mailing Address - Zip Code:04864-4528
Mailing Address - Country:US
Mailing Address - Phone:207-596-3710
Mailing Address - Fax:
Practice Address - Street 1:56 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-5900
Practice Address - Country:US
Practice Address - Phone:207-921-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP191228363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health