Provider Demographics
NPI:1083449912
Name:WALTO, BRIELLE MACKENZIE
Entity type:Individual
Prefix:
First Name:BRIELLE
Middle Name:MACKENZIE
Last Name:WALTO
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 1:19 PEACOCK CIR
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2254
Mailing Address - Country:US
Mailing Address - Phone:609-613-8673
Mailing Address - Fax:
Practice Address - Street 1:19 PEACOCK CIR
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2254
Practice Address - Country:US
Practice Address - Phone:609-613-8673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-02
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer