Provider Demographics
NPI:1639378706
Name:WALTON, RENAE MICHELLE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:RENAE
Middle Name:MICHELLE
Last Name:WALTON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15080 IDLEWILD RD STE F
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-3601
Mailing Address - Country:US
Mailing Address - Phone:704-579-1415
Mailing Address - Fax:043-237-2097
Practice Address - Street 1:15080 IDLEWILD RD STE F
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28104-3601
Practice Address - Country:US
Practice Address - Phone:704-579-1415
Practice Address - Fax:704-323-7209
Is Sole Proprietor?:No
Enumeration Date:2007-07-17
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004002363LF0000X
NC50042363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593282OtherMEDICARE INDIVIDUAL NUMBER
NC2593282OtherMEDICARE INDIVIDUAL NUMBER