MEDICARE: SANDY WALTERS RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN082131	AZ

General Provider Information

NPI Number	:	1316177694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDY WALTERS RN

Provider Business Mailing Address
First Line	:	3050 TRIPOLI DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86404-1529
Country	:	US
Telephone Number	:	928-412-1070
Fax Number	:

Provider Business Practice Location Address
First Line	:	3050 TRIPOLI DR
Second Line	:
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86404-1529
Country	:	US
Telephone Number	:	928-412-1070
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2009
Last Update Date	:	07/21/2009

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