Provider Demographics
NPI:1730954710
Name:WALTON, DIANA LEE
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LEE
Last Name:WALTON
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 1:717 N CENTER DR NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8215
Mailing Address - Country:US
Mailing Address - Phone:616-432-7208
Mailing Address - Fax:
Practice Address - Street 1:717 N CENTER DR NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49544-8215
Practice Address - Country:US
Practice Address - Phone:616-432-7208
Practice Address - Fax:616-784-1281
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist