Provider Demographics
NPI:1790143733
Name:WALKER, MITZI (RN)
Entity Type:Individual
Prefix:
First Name:MITZI
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:THEORTIS
Other - Middle Name:
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:676 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1510
Mailing Address - Country:US
Mailing Address - Phone:773-474-9150
Mailing Address - Fax:
Practice Address - Street 1:676 BROOKWOOD DR
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1510
Practice Address - Country:US
Practice Address - Phone:773-474-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-231858163WP0807X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent