Provider Demographics
NPI:1598549578
Name:WALKER, KIM SUSAN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:SUSAN
Last Name:WALKER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:LAKE ARROWHEAD
Mailing Address - State:CA
Mailing Address - Zip Code:92352-0925
Mailing Address - Country:US
Mailing Address - Phone:909-744-7591
Mailing Address - Fax:
Practice Address - Street 1:27397 NORTH BAY ROAD
Practice Address - Street 2:
Practice Address - City:LAKE ARROWHEAD
Practice Address - State:CA
Practice Address - Zip Code:92352-0925
Practice Address - Country:US
Practice Address - Phone:909-744-7591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026513363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily