Provider Demographics
NPI:1760669170
Name:WALTERS, KATHLEEN RAE (LVN)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RAE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1447 E STATE HIGHWAY 71 UNIT C
Mailing Address - Street 2:
Mailing Address - City:LLANO
Mailing Address - State:TX
Mailing Address - Zip Code:78643-3534
Mailing Address - Country:US
Mailing Address - Phone:325-247-5895
Mailing Address - Fax:325-247-3252
Practice Address - Street 1:819 WATER ST STE 300
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-5330
Practice Address - Country:US
Practice Address - Phone:830-258-5430
Practice Address - Fax:830-792-5771
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX140995164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140995OtherLVN LICENSE