Healthcare Provider Details

I. General information

NPI: 1740931302
Provider Name (Legal Business Name): WALTER MASON JAHNA APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 02/21/2022
Certification Date: 02/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4409 SUN N LAKE BLVD
SEBRING FL
33872-2170
US

IV. Provider business mailing address

997 ENTRANCE RD
AVON PARK FL
33825-9105
US

V. Phone/Fax

Practice location:
  • Phone: 863-402-3480
  • Fax: 863-402-3483
Mailing address:
  • Phone: 863-443-6329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11017555
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: