MEDICARE: JOANNA WALTERS AES

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	174400000X	Specialist	FB9770392	FL
2	247200000X	Other Technician	FB9770392	FL

General Provider Information

NPI Number	:	1689432627
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANNA WALTERS AES

Provider Business Mailing Address
First Line	:	1805 REDWOOD AVE
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-2439
Country	:	US
Telephone Number	:	407-310-9626
Fax Number	:

Provider Business Practice Location Address
First Line	:	1805 REDWOOD AVE
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-2439
Country	:	US
Telephone Number	:	407-310-9626
Fax Number	:

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

Provider Enumeration Date	:	03/12/2024
Last Update Date	:	03/12/2024

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