MEDICARE: KIM SUSAN WALKER NURSE PRACTITIONER

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	363LF0000X	Family Nurse Practitioner	95026513	CA

General Provider Information

NPI Number	:	1598549578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM SUSAN WALKER NURSE PRACTITIONER

Provider Business Mailing Address
First Line	:	PO BOX 925
Second Line	:
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352-0925
Country	:	US
Telephone Number	:	909-744-7591
Fax Number	:

Provider Business Practice Location Address
First Line	:	27397 NORTH BAY ROAD
Second Line	:
City	:	LAKE ARROWHEAD
State	:	CA
Zip	:	92352-0925
Country	:	US
Telephone Number	:	909-744-7591
Fax Number	:

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

Provider Enumeration Date	:	08/22/2023
Last Update Date	:	08/22/2023

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