MEDICARE: JOHNETTA J WALKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	KK300035	CA

General Provider Information

NPI Number	:	1174113138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNETTA J WALKER

Provider Business Mailing Address
First Line	:	3542 FRUITVALE AVE # 212
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94602-2327
Country	:	US
Telephone Number	:	510-812-2428
Fax Number	:

Provider Business Practice Location Address
First Line	:	4152 MACARTHUR BLVD
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94619-1906
Country	:	US
Telephone Number	:	510-812-2428
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2021
Last Update Date	:	01/24/2021

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