Provider Demographics
NPI:1376169136
Name:WALTERS, MARY COLLEEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:COLLEEN
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 1:517 HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:BARBERTON
Mailing Address - State:OH
Mailing Address - Zip Code:44203-2715
Mailing Address - Country:US
Mailing Address - Phone:330-564-3450
Mailing Address - Fax:
Practice Address - Street 1:380 S PORTAGE PATH
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-2326
Practice Address - Country:US
Practice Address - Phone:330-564-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.147125.MED-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse