Provider Demographics
NPI:1780190595
Name:WALTERS-SMITH, KONDI O (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KONDI
Middle Name:O
Last Name:WALTERS-SMITH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12114 BLUE FLAG WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2753
Mailing Address - Country:US
Mailing Address - Phone:301-741-0307
Mailing Address - Fax:
Practice Address - Street 1:12114 BLUE FLAG WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2753
Practice Address - Country:US
Practice Address - Phone:301-741-0307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR180720363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily