Provider Demographics
NPI:1013089630
Name:WALSH, ROBERTA J (RN,CNP)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:J
Last Name:WALSH
Suffix:
Gender:F
Credentials:RN,CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SHELDON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4513
Mailing Address - Country:US
Mailing Address - Phone:616-459-4212
Mailing Address - Fax:616-774-9022
Practice Address - Street 1:201 SHELDON BLVD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4513
Practice Address - Country:US
Practice Address - Phone:616-459-4212
Practice Address - Fax:616-774-9022
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704075934363LP0808X
MI163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4807934Medicaid
MI4807934Medicaid