Provider Demographics
NPI:1558554592
Name:WALTERS, KARYN LESLIE (PTA)
Entity Type:Individual
Prefix:
First Name:KARYN
Middle Name:LESLIE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 E PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3643
Mailing Address - Country:US
Mailing Address - Phone:660-385-1307
Mailing Address - Fax:660-385-1307
Practice Address - Street 1:29612 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552-3702
Practice Address - Country:US
Practice Address - Phone:660-385-5797
Practice Address - Fax:660-385-1301
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO116816225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant