Provider Demographics
NPI:1861415515
Name:WALTER, GEORGETTE (ARNP)
Entity type:Individual
Prefix:
First Name:GEORGETTE
Middle Name:
Last Name:WALTER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950245
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0245
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4041 PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1601
Practice Address - Country:US
Practice Address - Phone:502-375-3242
Practice Address - Fax:502-375-4331
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY778P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY009450OtherSIHO - NORTON ICC
11480571OtherCAQH
KY78000064Medicaid
KYR33236Medicare UPIN
11480571OtherCAQH
IN196290CCCCMedicare PIN