Provider Demographics
NPI:1619385010
Name:WALTERS, MONICA (LAC)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 MONTGOMERY DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4815
Mailing Address - Country:US
Mailing Address - Phone:916-741-2960
Mailing Address - Fax:
Practice Address - Street 1:1120 MONTGOMERY DR
Practice Address - Street 2:SUITE D
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4815
Practice Address - Country:US
Practice Address - Phone:916-741-2960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC16009171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist