Healthcare Provider Details

I. General information

NPI: 1306211883
Provider Name (Legal Business Name): DENISE WALTER AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DENISE DELUCA

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 E NIZHONI BLVD
GALLUP NM
87301-5748
US

IV. Provider business mailing address

444 SAWYER DR
HARPERS FERRY WV
25425-5885
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-1000
  • Fax:
Mailing address:
  • Phone: 304-676-8468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number63349
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number63349
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number63349
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: