Healthcare Provider Details

I. General information

NPI: 1700887502
Provider Name (Legal Business Name): DIANE WALKER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 11/06/2022
Certification Date: 11/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S PINEY RD
CHESTER MD
21619-2619
US

IV. Provider business mailing address

115 S PINEY RD
CHESTER MD
21619-2619
US

V. Phone/Fax

Practice location:
  • Phone: 410-643-3007
  • Fax:
Mailing address:
  • Phone: 410-643-3007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number88082
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR163105
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: