Provider Demographics
NPI:1194996462
Name:WALTERS, CAROLYN S (BSN,RN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:S
Last Name:WALTERS
Suffix:
Gender:F
Credentials:BSN,RN
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:S
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN,RN
Mailing Address - Street 1:300 PRESTON DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1551
Mailing Address - Country:US
Mailing Address - Phone:304-624-6554
Mailing Address - Fax:304-624-5223
Practice Address - Street 1:300 PRESTON DR
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1551
Practice Address - Country:US
Practice Address - Phone:304-624-6554
Practice Address - Fax:304-624-5223
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV32999163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810004148Medicaid