Provider Demographics
NPI:1700109477
Name:KELLY M. WALKER DPM,PLLC
Entity type:Organization
Organization Name:KELLY M. WALKER DPM,PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:731-325-5360
Mailing Address - Street 1:1950 US HIGHWAY 51 BYP N
Mailing Address - Street 2:SUITE C
Mailing Address - City:DYERSBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38024-1897
Mailing Address - Country:US
Mailing Address - Phone:731-325-5360
Mailing Address - Fax:731-325-5365
Practice Address - Street 1:1950 US HIGHWAY 51 BYP N
Practice Address - Street 2:SUITE C
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-1897
Practice Address - Country:US
Practice Address - Phone:731-325-5360
Practice Address - Fax:731-325-5365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN786213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB107559OtherINDIVIDUAL PTAN
TXTXB107558OtherGROUP PTAN
TX6385400001Medicare NSC
TXTXB107559OtherINDIVIDUAL PTAN