Provider Demographics
NPI:1275366718
Name:WALTS, HEATHER
Entity type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:WALTS
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 1:1 CRESTLINE DR
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12167-1111
Mailing Address - Country:US
Mailing Address - Phone:607-214-4108
Mailing Address - Fax:
Practice Address - Street 1:1 CRESTLINE DR
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:NY
Practice Address - Zip Code:12167-1111
Practice Address - Country:US
Practice Address - Phone:607-214-4108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist