Provider Demographics
NPI:1740998731
Name:WALTON, NICHOLLE
Entity type:Individual
Prefix:
First Name:NICHOLLE
Middle Name:
Last Name:WALTON
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 1:261 N ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2617
Mailing Address - Country:US
Mailing Address - Phone:480-677-8282
Mailing Address - Fax:844-470-2777
Practice Address - Street 1:2640 W BASELINE RD STE 111
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-6492
Practice Address - Country:US
Practice Address - Phone:480-677-8282
Practice Address - Fax:844-470-2777
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ283098363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily