Provider Demographics
NPI:1689432627
Name:WALTERS, JOANNA (AES)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:AES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2439
Mailing Address - Country:US
Mailing Address - Phone:407-310-9626
Mailing Address - Fax:
Practice Address - Street 1:1805 REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32951-2439
Practice Address - Country:US
Practice Address - Phone:407-310-9626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFB9770392174400000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No174400000XOther Service ProvidersSpecialist