Provider Demographics
NPI:1457615684
Name:WALTER, LAUREN KAY (NP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:KAY
Last Name:WALTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:KAY
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:425 W COLONIAL DR STE 303
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6863
Mailing Address - Country:US
Mailing Address - Phone:904-745-3618
Mailing Address - Fax:904-722-4271
Practice Address - Street 1:4565 US HIGHWAY 17 STE 106
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4822
Practice Address - Country:US
Practice Address - Phone:317-274-2304
Practice Address - Fax:317-274-4554
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11027161363LF0000X
IN71004001A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000837787OtherANTHEM PIN
IN201181880Medicaid
IN233690016Medicare PIN