Provider Demographics
NPI:1730861840
Name:WALKER, TINA FAWN (FNP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:FAWN
Last Name:WALKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 CHERRYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31503-8027
Mailing Address - Country:US
Mailing Address - Phone:912-278-2784
Mailing Address - Fax:
Practice Address - Street 1:1900 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6357
Practice Address - Country:US
Practice Address - Phone:912-283-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN159326363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner