MEDICARE: JUDY WALTERS RN

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	163WP0807X	Child & Adolescent Psychiatric/Mental Health Registered Nurse	RN094084	GA

General Provider Information

NPI Number	:	1518190388
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUDY WALTERS RN

Provider Business Mailing Address
First Line	:	1620 HICKORY ST STE 404
Second Line	:
City	:	DALTON
State	:	GA
Zip	:	30720-2312
Country	:	US
Telephone Number	:	706-270-5002
Fax Number	:	706-270-5129

Provider Business Practice Location Address
First Line	:	705 N DIVISION ST NW
Second Line	:	BUILDING 315
City	:	ROME
State	:	GA
Zip	:	30165-1454
Country	:	US
Telephone Number	:	706-802-5870
Fax Number	:	706-805-0654

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

Provider Enumeration Date	:	08/27/2009
Last Update Date	:	08/27/2009

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