Healthcare Provider Details

I. General information

NPI: 1295603520
Provider Name (Legal Business Name): NIA WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2025
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4118 RAEFORD RD
FAYETTEVILLE NC
28304-3360
US

IV. Provider business mailing address

4118 RAEFORD RD
FAYETTEVILLE NC
28304-3360
US

V. Phone/Fax

Practice location:
  • Phone: 472-215-8665
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-15818
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: