Healthcare Provider Details

I. General information

NPI: 1396281549
Provider Name (Legal Business Name): MARIBETH WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2017
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 MARNE HWY STE 200A
MOORESTOWN NJ
08057-3128
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-291-8855
  • Fax: 856-291-8844
Mailing address:
  • Phone: 856-355-0340
  • Fax: 856-355-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ00697100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00697100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: