Provider Demographics
NPI:1215287917
Name:WALTERS, JENNIFER ANN (CNM)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:ANN
Last Name:WALTERS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANN
Other - Last Name:TRAMANTANA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:50 TIMBER TER
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:IL
Mailing Address - Zip Code:60013-1555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:388 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4735
Practice Address - Country:US
Practice Address - Phone:860-649-1120
Practice Address - Fax:860-645-8541
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000373367A00000X
VT1010134298367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000373OtherLICENSE
VT1010134298OtherLICENSE