Healthcare Provider Details

I. General information

NPI: 1386078418
Provider Name (Legal Business Name): SHELLY D WALTERS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLY D THEOBALD MD

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 07/23/2021
Certification Date: 07/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1921 STONECIPHER DR
ADA OK
74820-3439
US

IV. Provider business mailing address

301 CEDAR ST
OROFINO ID
83544-9029
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-3980
  • Fax:
Mailing address:
  • Phone: 208-476-4555
  • Fax: 208-476-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberML60390210
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM-15041
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38491
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: