Provider Demographics
NPI:1407836828
Name:WALTERS, KELLY NICOLE (CPNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 DUPONT CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-2793
Mailing Address - Country:US
Mailing Address - Phone:513-576-7700
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:210 N UNION ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:OH
Practice Address - Zip Code:45106-1124
Practice Address - Country:US
Practice Address - Phone:513-734-9050
Practice Address - Fax:513-734-9051
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN281265 NP06528363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2561624Medicaid
OH2565399Medicaid
OH2561624Medicaid