Healthcare Provider Details

I. General information

NPI: 1649851692
Provider Name (Legal Business Name): JADE NICOLE WALTER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-7226
US

IV. Provider business mailing address

4740 NW 39TH PL STE B
GAINESVILLE FL
32606-7226
US

V. Phone/Fax

Practice location:
  • Phone: 352-627-9350
  • Fax:
Mailing address:
  • Phone: 301-742-2031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS21244
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: