Provider Demographics
NPI:1912025438
Name:WALTERS, TONYA MARIE
Entity Type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:MARIE
Last Name:WALTERS
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 1:13136 STATE ROUTE 217
Mailing Address - Street 2:
Mailing Address - City:SCOTTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45678-8951
Mailing Address - Country:US
Mailing Address - Phone:740-886-6789
Mailing Address - Fax:
Practice Address - Street 1:13136 STATE ROUTE 217
Practice Address - Street 2:
Practice Address - City:SCOTTOWN
Practice Address - State:OH
Practice Address - Zip Code:45678-8951
Practice Address - Country:US
Practice Address - Phone:740-886-6789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2148956374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2148956Medicaid