Provider Demographics
NPI:1497183818
Name:WALKER, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:WALKER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 GREENE ST
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-2933
Mailing Address - Country:US
Mailing Address - Phone:301-682-2041
Mailing Address - Fax:301-732-6295
Practice Address - Street 1:72 GREENE ST
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-2933
Practice Address - Country:US
Practice Address - Phone:301-682-2041
Practice Address - Fax:301-732-6295
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP013898363L00000X
MDR207755363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029341620001Medicaid
PA1029341620001Medicaid
PA364732Medicare PIN