Healthcare Provider Details

I. General information

NPI: 1336514074
Provider Name (Legal Business Name): MRS. COURTNEY BENNETT WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 07/27/2022
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 N GROSS RD STE 201
KINGSLAND GA
31548-6277
US

IV. Provider business mailing address

308 LONG POINT CIR
SAINT MARYS GA
31558-4384
US

V. Phone/Fax

Practice location:
  • Phone: 912-729-2795
  • Fax:
Mailing address:
  • Phone: 904-699-8268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number313498
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9281279
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number313498
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: