Provider Demographics
NPI:1518221175
Name:WALTERS, LAUREN M (CFNP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:M
Last Name:WALTERS
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-758-3100
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:1238 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-9519
Practice Address - Country:US
Practice Address - Phone:601-758-3100
Practice Address - Fax:601-758-3060
Is Sole Proprietor?:No
Enumeration Date:2012-06-28
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR881262363L00000X
MS881262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00509295Medicaid