Basic Information
| Provider Information | |||||||||
| NPI: | 1619157336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTON | ||||||||
| FirstName: | GWENITA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CBHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 AVENUE F NE | ||||||||
| Address2: | |||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633855179 | ||||||||
| FaxNumber: | 8633854678 | ||||||||
| Practice Location | |||||||||
| Address1: | 5825 N HIGHWAY 27 | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338701216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633855179 | ||||||||
| FaxNumber: | 8633854678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.