Provider Demographics
NPI:1417918830
Name:WALTON, AUDREY ALETHA (NP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ALETHA
Last Name:WALTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 THOMAS RD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7366
Mailing Address - Country:US
Mailing Address - Phone:318-322-9882
Mailing Address - Fax:318-322-2006
Practice Address - Street 1:102 THOMAS RD
Practice Address - Street 2:SUITE 117
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7366
Practice Address - Country:US
Practice Address - Phone:318-322-9882
Practice Address - Fax:318-322-2006
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1193054Medicaid
LAQ48647Medicare UPIN
LA4H543Medicare ID - Type Unspecified