Provider Demographics
NPI:1598425704
Name:WALTERS, MARTHA (LPN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4127
Mailing Address - Country:US
Mailing Address - Phone:336-794-6058
Mailing Address - Fax:
Practice Address - Street 1:9101 SMITH CROSSING DR
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-0150
Practice Address - Country:US
Practice Address - Phone:336-734-8706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND72627164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse