Healthcare Provider Details

I. General information

NPI: 1679884001
Provider Name (Legal Business Name): STEPHANIE RAE WALTER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2010
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 ALGER ST SE
GRAND RAPIDS MI
49507-3530
US

IV. Provider business mailing address

733 ALGER ST SE
GRAND RAPIDS MI
49507-3530
US

V. Phone/Fax

Practice location:
  • Phone: 616-243-9513
  • Fax:
Mailing address:
  • Phone: 616-243-9513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101018635
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: