Healthcare Provider Details

I. General information

NPI: 1134798564
Provider Name (Legal Business Name): JENNIFER WALKER PHELPS NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107A BROOKDALE ST
MARTINSVILLE VA
24112-4501
US

IV. Provider business mailing address

213 S JEFFERSON ST
ROANOKE VA
24011-1705
US

V. Phone/Fax

Practice location:
  • Phone: 276-670-3300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0001207898
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024181461
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: