Provider Demographics
NPI:1881202505
Name:WALTER, TISHA LINN (CPNP)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:LINN
Last Name:WALTER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3914 CENTREVILLE RD STE 225
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-3045
Mailing Address - Country:US
Mailing Address - Phone:703-956-6301
Mailing Address - Fax:
Practice Address - Street 1:7015C MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310-3420
Practice Address - Country:US
Practice Address - Phone:703-971-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024197661363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics