Provider Demographics
NPI:1629852082
Name:WALTERS, ABIGAIL LILLA
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:LILLA
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 1:897 JOHNSTONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30204-3313
Mailing Address - Country:US
Mailing Address - Phone:770-680-6421
Mailing Address - Fax:
Practice Address - Street 1:382 RACETRACK RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-1022
Practice Address - Country:US
Practice Address - Phone:678-205-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT016800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist