Basic Information
| Provider Information | |||||||||
| NPI: | 1386078418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THEOBALD | ||||||||
| OtherFirstName: | SHELLY | ||||||||
| OtherMiddleName: | D | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | OROFINO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835449029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084764555 | ||||||||
| FaxNumber: | 2084765385 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 STONECIPHER DR | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748203439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804363980 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2013 | ||||||||
| LastUpdateDate: | 07/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ML60390210 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | M-15041 | ID | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 38491 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.