Healthcare Provider Details

I. General information

NPI: 1003395716
Provider Name (Legal Business Name): WALTER RICHARD SHEILDS JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 WOODLANE RD
MT HOLLY NJ
08060
US

IV. Provider business mailing address

770 WOODLANE RD
MT HOLLY NJ
08060
US

V. Phone/Fax

Practice location:
  • Phone: 856-495-4601
  • Fax:
Mailing address:
  • Phone: 856-495-4601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number26NR10941600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: