Provider Demographics
NPI:1396041240
Name:WALTERS, TANISHA (LAC, DIPLOM)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:WALTERS
Suffix:
Gender:F
Credentials:LAC, DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15-2660 PAHOA VILLAGE RD.
Mailing Address - Street 2:STE 203 #285
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778
Mailing Address - Country:US
Mailing Address - Phone:303-482-7176
Mailing Address - Fax:
Practice Address - Street 1:15-1927 2ND AVE.
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749
Practice Address - Country:US
Practice Address - Phone:303-482-7176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-09
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIACU-1440171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist