Provider Demographics
NPI:1013213958
Name:WALTER, KENNETH MICHAEL (NP-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:WALTER
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 S WASHINGTON ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6421
Mailing Address - Country:US
Mailing Address - Phone:248-236-8333
Mailing Address - Fax:248-236-8666
Practice Address - Street 1:72 S WASHINGTON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6421
Practice Address - Country:US
Practice Address - Phone:248-236-8333
Practice Address - Fax:248-236-8666
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230530363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner