Provider Demographics
NPI:1902350960
Name:WALKER, SHUNDRYIA
Entity Type:Individual
Prefix:
First Name:SHUNDRYIA
Middle Name:
Last Name:WALKER
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 1:2770 KORINK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5707
Mailing Address - Country:US
Mailing Address - Phone:334-513-9161
Mailing Address - Fax:
Practice Address - Street 1:2770 KORINK AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5707
Practice Address - Country:US
Practice Address - Phone:334-513-9161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL74553991710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman