Provider Demographics
NPI:1811299621
Name:WALTERS, MELINDA SUE (ABO)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:SUE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:ABO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9911 KENNERLY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2700
Mailing Address - Country:US
Mailing Address - Phone:314-842-0420
Mailing Address - Fax:314-842-1407
Practice Address - Street 1:9911 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2700
Practice Address - Country:US
Practice Address - Phone:341-842-0420
Practice Address - Fax:314-842-1407
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14412156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician