Provider Demographics
NPI:1487689873
Name:WALTERS, VONDA FAYE (CRNA)
Entity Type:Individual
Prefix:
First Name:VONDA
Middle Name:FAYE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-2559
Mailing Address - Country:US
Mailing Address - Phone:601-369-2021
Mailing Address - Fax:
Practice Address - Street 1:1710 W 12TH ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2559
Practice Address - Country:US
Practice Address - Phone:601-369-2021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR522384367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01224218Medicaid
MS00119538Medicaid
MS00119538Medicaid