Provider Demographics
NPI:1245948041
Name:WALTER, RENEE ELLEN (APN)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:ELLEN
Last Name:WALTER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTN PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:2367 B CYPRESS CIRCLE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8921
Practice Address - Country:US
Practice Address - Phone:843-349-1001
Practice Address - Fax:843-349-1008
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NR11450300OtherRN LICENSE
NJ26NJ01393800OtherAPN LICENSE
SCNP9477Medicaid