Provider Demographics
NPI:1891303913
Name:WALKER, COURTNEY (COA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WALKER
Suffix:
Gender:F
Credentials:COA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3475 MORGAN RD
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-5504
Mailing Address - Country:US
Mailing Address - Phone:470-242-4733
Mailing Address - Fax:866-398-5005
Practice Address - Street 1:132 STANLEY CT STE M
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-9061
Practice Address - Country:US
Practice Address - Phone:470-242-4733
Practice Address - Fax:866-398-5005
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA180309156FX1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA180309OtherCOA