Basic Information
| Provider Information | |||||||||
| NPI: | 1053939215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | ROCHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WIDICK | ||||||||
| OtherFirstName: | KATIE | ||||||||
| OtherMiddleName: | ROCHELLE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1275 DICK LONAS RD UNIT 101 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655844747 | ||||||||
| FaxNumber: | 8655841363 | ||||||||
| Practice Location | |||||||||
| Address1: | 7744 CONNER RD | ||||||||
| Address2: | |||||||||
| City: | POWELL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378493509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655469751 | ||||||||
| FaxNumber: | 8339082167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2020 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN0000177266 | TN | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 29659 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.