Provider Demographics
NPI:1184919367
Name:WALTER, TINA
Entity type:Individual
Prefix:MR
First Name:TINA
Middle Name:
Last Name:WALTER
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:PO BOX 4084
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96745-4084
Mailing Address - Country:US
Mailing Address - Phone:808-990-3274
Mailing Address - Fax:
Practice Address - Street 1:75-6082 ALII DR
Practice Address - Street 2:STE 10A
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-4303
Practice Address - Country:US
Practice Address - Phone:808-990-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT 11747174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator