Healthcare Provider Details

I. General information

NPI: 1396144135
Provider Name (Legal Business Name): LYDIA MICHELLE WALTERS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2014
Last Update Date: 08/10/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N. STATE STREET
JACKSON MS
39216-4505
US

IV. Provider business mailing address

2500 N. STATE STREET
JACKSON MS
39216-4505
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-1000
  • Fax:
Mailing address:
  • Phone: 601-815-6960
  • Fax: 601-815-9760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNUR-APRN-LIC-124631
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: