Healthcare Provider Details

I. General information

NPI: 1699804419
Provider Name (Legal Business Name): RETONYA J WALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 12/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 W BROADWAY ST
MUSKOGEE OK
74401-2718
US

IV. Provider business mailing address

2901 W BROADWAY ST
MUSKOGEE OK
74401-2718
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-5828
  • Fax: 918-683-5828
Mailing address:
  • Phone: 918-683-5828
  • Fax: 918-683-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number5459050001
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: