Healthcare Provider Details

I. General information

NPI: 1407836828
Provider Name (Legal Business Name): KELLY NICOLE WALTERS CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N UNION ST
BETHEL OH
45106-1124
US

IV. Provider business mailing address

5400 DUPONT CIR SUITE A
MILFORD OH
45150-2793
US

V. Phone/Fax

Practice location:
  • Phone: 513-734-9050
  • Fax: 513-734-9051
Mailing address:
  • Phone: 513-576-7700
  • Fax: 513-576-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN281265 NP06528
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: