Provider Demographics
NPI:1629010426
Name:WALTERS, JEANNICE (PA)
Entity Type:Individual
Prefix:
First Name:JEANNICE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5390 N ACADEMY BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4062
Mailing Address - Country:US
Mailing Address - Phone:719-268-9000
Mailing Address - Fax:719-268-6687
Practice Address - Street 1:5390 N ACADEMY BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4062
Practice Address - Country:US
Practice Address - Phone:719-268-9000
Practice Address - Fax:719-268-6687
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant