Healthcare Provider Details

I. General information

NPI: 1548633431
Provider Name (Legal Business Name): NINA WALTZER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2015
Last Update Date: 11/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX DRAWER E
PARCHMAN MS
38738
US

IV. Provider business mailing address

745 LENOX DR
JACKSON MS
39211-4106
US

V. Phone/Fax

Practice location:
  • Phone: 662-745-6611
  • Fax:
Mailing address:
  • Phone: 769-610-1296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR878503
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: