Healthcare Provider Details

I. General information

NPI: 1255090965
Provider Name (Legal Business Name): TERESA RENEE WALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/27/2021
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1003 BELLEFONTAINE AVE STE 125
LIMA OH
45804-1867
US

IV. Provider business mailing address

1001 BELLEFONTAINE AVE
LIMA OH
45804-2800
US

V. Phone/Fax

Practice location:
  • Phone: 419-998-8207
  • Fax: 419-998-8216
Mailing address:
  • Phone: 419-228-3335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.0029705
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: