Provider Demographics
NPI:1851379382
Name:WALTERS, PEGGY ANN (RN FNP)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:ANN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GOSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:47433-0009
Mailing Address - Country:US
Mailing Address - Phone:812-879-4222
Mailing Address - Fax:812-879-4834
Practice Address - Street 1:7 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GOSPORT
Practice Address - State:IN
Practice Address - Zip Code:47433
Practice Address - Country:US
Practice Address - Phone:812-879-4222
Practice Address - Fax:812-879-4834
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002258A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ76939Medicare UPIN
IN610590IMedicare ID - Type Unspecified