Healthcare Provider Details

I. General information

NPI: 1841892593
Provider Name (Legal Business Name): DORMICO LATASHIA WALKER DNP, MSN-L, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 09/14/2024
Certification Date: 09/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4633 OLD IRONSIDES DR STE 304
SANTA CLARA CA
95054-1846
US

IV. Provider business mailing address

3101 N CENTRAL AVE STE 550
PHOENIX AZ
85012-2635
US

V. Phone/Fax

Practice location:
  • Phone: 323-745-8323
  • Fax:
Mailing address:
  • Phone: 602-230-7373
  • Fax: 602-682-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN202021
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95027503
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-249922
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN95310089
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: