Healthcare Provider Details

I. General information

NPI: 1669423976
Provider Name (Legal Business Name): TIMOTHY P WALTON MSN, RN, CPNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

IV. Provider business mailing address

5471 DR MARTIN LUTHER KING DR
SAINT LOUIS MO
63112-4265
US

V. Phone/Fax

Practice location:
  • Phone: 314-367-5820
  • Fax: 314-623-6326
Mailing address:
  • Phone: 314-367-5820
  • Fax: 314-623-6326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN133867
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number133867
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: