Healthcare Provider Details

I. General information

NPI: 1063451342
Provider Name (Legal Business Name): VICKIE LEONA WALTERS LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 BROAD ST
COLUMBIA MS
39429-3038
US

IV. Provider business mailing address

1485 BROWNS BRIDGE RD
HATTIESBURG MS
39401-8739
US

V. Phone/Fax

Practice location:
  • Phone: 601-444-0030
  • Fax:
Mailing address:
  • Phone: 601-434-9361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA3440
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: