Healthcare Provider Details

I. General information

NPI: 1518098656
Provider Name (Legal Business Name): KATHLEEN R. WALTERS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MCCLELLAN AVE STE 300
PENNSAUKEN NJ
08109-0001
US

IV. Provider business mailing address

2500 MCCLELLAN AVE STE 300
PENNSAUKEN NJ
08109-0001
US

V. Phone/Fax

Practice location:
  • Phone: 856-361-2725
  • Fax: 856-435-1271
Mailing address:
  • Phone: 856-361-2725
  • Fax: 856-435-1271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number26NO09656700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: