Provider Demographics
NPI:1497045272
Name:WALSH, NICOLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 KINGS HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3162
Mailing Address - Country:US
Mailing Address - Phone:856-853-8730
Mailing Address - Fax:856-845-7198
Practice Address - Street 1:831 KINGS HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08096-3162
Practice Address - Country:US
Practice Address - Phone:856-853-8730
Practice Address - Fax:856-845-7198
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00324200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily