Provider Demographics
NPI:1518098656
Name:WALTERS, KATHLEEN R (RN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:R
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MCCLELLAN AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-0001
Mailing Address - Country:US
Mailing Address - Phone:856-361-2725
Mailing Address - Fax:856-435-1271
Practice Address - Street 1:2500 MCCLELLAN AVE STE 300
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08109-0001
Practice Address - Country:US
Practice Address - Phone:856-361-2725
Practice Address - Fax:856-435-1271
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO09656700163WP0808X
MO2002011438363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO425840600Medicaid
MO000081442Medicare ID - Type UnspecifiedMISSOURI MEDICARE
MOOTH000Medicare UPIN