Provider Demographics
NPI:1174822191
Name:WALTERS, AMANDA MAE
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MAE
Last Name:WALTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 123
Mailing Address - Street 2:
Mailing Address - City:TULLY
Mailing Address - State:NY
Mailing Address - Zip Code:13159-0123
Mailing Address - Country:US
Mailing Address - Phone:607-232-2961
Mailing Address - Fax:
Practice Address - Street 1:38 STATE STREET
Practice Address - Street 2:
Practice Address - City:TULLY
Practice Address - State:NY
Practice Address - Zip Code:13159-0123
Practice Address - Country:US
Practice Address - Phone:607-232-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator