Healthcare Provider Details

I. General information

NPI: 1811882533
Provider Name (Legal Business Name): JENNELLE WALTON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2025
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 N. MECHANIC STREET
CARTHAGE NY
13619
US

IV. Provider business mailing address

117 N. MECHANIC STREET
CARTHAGE NY
13619
US

V. Phone/Fax

Practice location:
  • Phone: 315-493-4187
  • Fax: 315-370-3115
Mailing address:
  • Phone: 315-493-4187
  • Fax: 315-370-3115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number033898
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: