Healthcare Provider Details

I. General information

NPI: 1619325438
Provider Name (Legal Business Name): BRANDDY WALTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3617 S PACIFIC HWY
MEDFORD OR
97501-8957
US

IV. Provider business mailing address

931 CHEVY WAY
MEDFORD OR
97504-4127
US

V. Phone/Fax

Practice location:
  • Phone: 541-535-6239
  • Fax: 541-842-2212
Mailing address:
  • Phone: 541-690-3555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201505008RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202212643NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: