Provider Demographics
NPI:1669941027
Name:ENOCH, WALETTRA CHARMESE (NP)
Entity type:Individual
Prefix:
First Name:WALETTRA
Middle Name:CHARMESE
Last Name:ENOCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7507 SOCIETY DR
Mailing Address - Street 2:
Mailing Address - City:CLAYMONT
Mailing Address - State:DE
Mailing Address - Zip Code:19703-1775
Mailing Address - Country:US
Mailing Address - Phone:215-397-7104
Mailing Address - Fax:
Practice Address - Street 1:156 WILLIAM ST RM 303
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-5307
Practice Address - Country:US
Practice Address - Phone:888-803-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-15
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELP0010478363LP2300X
NY310872363LP2300X
PASP019360363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1912199415Medicaid