Provider Demographics
NPI:1720601065
Name:WALKER, TENEA LATRICE
Entity Type:Individual
Prefix:
First Name:TENEA
Middle Name:LATRICE
Last Name:WALKER
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:PO BOX 1012
Mailing Address - Street 2:
Mailing Address - City:AYLETT
Mailing Address - State:VA
Mailing Address - Zip Code:23009-1012
Mailing Address - Country:US
Mailing Address - Phone:804-246-8742
Mailing Address - Fax:
Practice Address - Street 1:2780 MAHIXON RD
Practice Address - Street 2:
Practice Address - City:MANQUIN
Practice Address - State:VA
Practice Address - Zip Code:23106-2318
Practice Address - Country:US
Practice Address - Phone:804-246-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAA67201169347C00000X
VAA64201169347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA347C00000X-Medicaid