Healthcare Provider Details

I. General information

NPI: 1376576413
Provider Name (Legal Business Name): PATTI JANE WALTERS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5342 DUDLEY BLVD BLDG 98 ROOM 1K05
MCCLELLAN CA
95652-1012
US

IV. Provider business mailing address

7036 YARROW WAY
CITRUS HEIGHTS CA
95610-4026
US

V. Phone/Fax

Practice location:
  • Phone: 916-561-7525
  • Fax: 916-561-7529
Mailing address:
  • Phone: 916-722-4809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number423996
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: