Provider Demographics
NPI:1407995392
Name:WALTERS, LINDA BACON (RD)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:BACON
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4122 BRADFORD LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1065
Mailing Address - Country:US
Mailing Address - Phone:423-262-0462
Mailing Address - Fax:423-431-6060
Practice Address - Street 1:4122 BRADFORD LN
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1065
Practice Address - Country:US
Practice Address - Phone:423-262-0462
Practice Address - Fax:423-431-6060
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000001309133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN00B29Medicaid