Healthcare Provider Details

I. General information

NPI: 1174274815
Provider Name (Legal Business Name): KALLYOPI VAFIADIS WALTON APRN, CPNP-AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 MUELLER BLVD
AUSTIN TX
78723-3051
US

IV. Provider business mailing address

4368 WESTDALE CT
FORT WORTH TX
76109-4929
US

V. Phone/Fax

Practice location:
  • Phone: 512-324-0000
  • Fax:
Mailing address:
  • Phone: 817-627-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number864475
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number1069774
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: