Basic Information
| Provider Information | |||||||||
| NPI: | 1336759984 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | DEANNE | ||||||||
| MiddleName: | ANGELA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 253 FREDERICK ST | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187042711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705503245 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 E MOUNTAIN DR | ||||||||
| Address2: | |||||||||
| City: | WILKES BARRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187110027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708087300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2020 | ||||||||
| LastUpdateDate: | 08/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | SP022340 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.