Provider Demographics
NPI:1801482294
Name:WALTERS, CHADBOURNE (APNP)
Entity type:Individual
Prefix:
First Name:CHADBOURNE
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2105 E ENTERPRISE AVE
Mailing Address - Street 2:STE 111
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2105 E ENTERPRISE AVE
Practice Address - Street 2:STE 111
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-7862
Practice Address - Country:US
Practice Address - Phone:920-731-6611
Practice Address - Fax:920-731-6732
Is Sole Proprietor?:No
Enumeration Date:2020-12-19
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10333363LF0000X
WI10333-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10333-33OtherWISCONSIN DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES (ADVANCED PRACTICE NURS
WI187532-30OtherWISCONSIN DEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES (REGISTERED NURSE)