Provider Demographics
NPI:1629515226
Name:WALTERS, PRISCILLA
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4901 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-7627
Mailing Address - Country:US
Mailing Address - Phone:954-482-3360
Mailing Address - Fax:954-894-1188
Practice Address - Street 1:4901 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-7627
Practice Address - Country:US
Practice Address - Phone:954-482-3360
Practice Address - Fax:954-894-1188
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-21
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12519305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLW436671717290Medicaid