Provider Demographics
NPI:1366001240
Name:WALTON, JOHNNIE HENDERSON VI (ATC)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:HENDERSON
Last Name:WALTON
Suffix:VI
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 WINDERMERE AVE
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-1313
Mailing Address - Country:US
Mailing Address - Phone:650-861-9715
Mailing Address - Fax:
Practice Address - Street 1:7447 MORTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-4207
Practice Address - Country:US
Practice Address - Phone:650-861-9715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer