Provider Demographics
NPI:1710498803
Name:WALTERS, KIMBERLY ANN
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
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 1:11572 17TH AND C. STREET
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98433
Mailing Address - Country:US
Mailing Address - Phone:253-967-4989
Mailing Address - Fax:
Practice Address - Street 1:11572 17TH AND C. STREET
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98433
Practice Address - Country:US
Practice Address - Phone:253-967-4989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
126800000X, 174H00000X
WA126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
No174H00000XOther Service ProvidersHealth Educator