Provider Demographics
NPI:1942601778
Name:WALTON, TANJA
Entity Type:Individual
Prefix:
First Name:TANJA
Middle Name:
Last Name:WALTON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:TANJA
Other - Middle Name:G
Other - Last Name:WALTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1400 S LIMIT AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:SEDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:65301-5116
Mailing Address - Country:US
Mailing Address - Phone:660-287-2454
Mailing Address - Fax:660-826-5174
Practice Address - Street 1:1400 S LIMIT AVE STE 9
Practice Address - Street 2:
Practice Address - City:SEDALIA
Practice Address - State:MO
Practice Address - Zip Code:65301-5116
Practice Address - Country:US
Practice Address - Phone:660-826-5885
Practice Address - Fax:660-826-5174
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-11
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO037428164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse