Provider Demographics
NPI:1568910024
Name:WALTON, PAIGE M (APRN)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:M
Last Name:WALTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:M
Other - Last Name:COOGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-562-4363
Mailing Address - Fax:502-562-4373
Practice Address - Street 1:529 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3229
Practice Address - Country:US
Practice Address - Phone:502-562-4363
Practice Address - Fax:502-562-4373
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010711363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100450110Medicaid
IN201411650Medicaid
KY7100450110Medicaid