Healthcare Provider Details

I. General information

NPI: 1790808731
Provider Name (Legal Business Name): KAREN RUTH WALTERS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1308 CRADDUCK RD
ADA OK
74820-8442
US

IV. Provider business mailing address

14630 COUNTY ROAD 3501
ADA OK
74820-2754
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-3699
  • Fax: 580-421-9828
Mailing address:
  • Phone: 580-436-0683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberR0049232
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: