Provider Demographics
NPI:1700150935
Name:WALTERS, HOLLIE R
Entity Type:Individual
Prefix:
First Name:HOLLIE
Middle Name:R
Last Name:WALTERS
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 1:801 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-2351
Mailing Address - Country:US
Mailing Address - Phone:580-564-9252
Mailing Address - Fax:
Practice Address - Street 1:801 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2351
Practice Address - Country:US
Practice Address - Phone:580-564-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner