Healthcare Provider Details

I. General information

NPI: 1124615257
Provider Name (Legal Business Name): RANITA A WALKER CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 N 57TH ST
EAST SAINT LOUIS IL
62203-1304
US

IV. Provider business mailing address

514 N 57TH ST
EAST SAINT LOUIS IL
62203-1304
US

V. Phone/Fax

Practice location:
  • Phone: 618-772-2721
  • Fax:
Mailing address:
  • Phone: 618-772-2721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License NumberF2X4T9Q2
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: