Healthcare Provider Details

I. General information

NPI: 1326518937
Provider Name (Legal Business Name): KRISTIE NICOLE WALTON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2018
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CENTRAL AVE
CLARK NJ
07066-1116
US

IV. Provider business mailing address

469 MORRIS AVE STE 3
ELIZABETH NJ
07208-2904
US

V. Phone/Fax

Practice location:
  • Phone: 732-574-1399
  • Fax: 732-574-1433
Mailing address:
  • Phone: 732-574-1399
  • Fax: 908-512-7300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26NJ00857600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: