Provider Demographics
NPI:1356985287
Name:WALTERS, SERICCA LYNN (RD LD)
Entity type:Individual
Prefix:MRS
First Name:SERICCA
Middle Name:LYNN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20731 W HASKELL LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HASKELL
Mailing Address - State:OK
Mailing Address - Zip Code:74436-5039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 HONOR HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1318
Practice Address - Country:US
Practice Address - Phone:918-351-4752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2476133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered