Provider Demographics
NPI:1851627343
Name:WALDEN, ELIZABETH SUE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:SUE
Last Name:WALDEN
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 1:220 PAWNEE TRL
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-4032
Mailing Address - Country:US
Mailing Address - Phone:606-231-8974
Mailing Address - Fax:
Practice Address - Street 1:220 PAWNEE TRL
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-4032
Practice Address - Country:US
Practice Address - Phone:606-231-8974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-19
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist