Provider Demographics
NPI:1851682736
Name:WALTERS, IRENE KAY (APRN)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:KAY
Last Name:WALTERS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DOG HILL RD
Mailing Address - Street 2:
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241-2106
Mailing Address - Country:US
Mailing Address - Phone:860-779-0321
Mailing Address - Fax:
Practice Address - Street 1:11 DOG HILL RD
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-2106
Practice Address - Country:US
Practice Address - Phone:860-779-0321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT100280363LP0808X
OR201907687NP-PP363LP0808X
CT7567363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1851682736Medicaid
MTM011004524Medicare Oscar/Certification