Basic Information
| Provider Information | |||||||||
| NPI: | 1316582687 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3545 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083465562 | ||||||||
| FaxNumber: | 7083462059 | ||||||||
| Practice Location | |||||||||
| Address1: | 3545 W 95TH ST | ||||||||
| Address2: | |||||||||
| City: | EVERGREEN PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 608052135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083465562 | ||||||||
| FaxNumber: | 7083462059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2019 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209020072 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 020072 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.