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General NPI Number Information
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NPI Number | 1710437074
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Entity Type | Organization
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Legal Business Name | WALTON FAMILY CARE CLINIC, LLC
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Dates
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Enumeration Date | 10/11/2016
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Last Update Date | 02/07/2017
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Provider Practice Location Address
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Address Line | 228 STARLYN AVE
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City | NEW ALBANY
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State | MS
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Zip | 38652-2428
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Country | US
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Telephone | 662-539-7383
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Fax | 662-539-7661
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Provider Business Mailing Address
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Address Line | PO BOX 611
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City | NEW ALBANY
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State | MS
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Zip | 38652-0611
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Country | US
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Telephone | 662-539-7383
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Fax | 662-539-7661
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Authorized Official
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Title or Position | OWNER
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Name | DR. TYRONGILIA Q WALTON
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Credential | DNP
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Telephone | 662-539-7383
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | R871879
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License Number State | MS
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