Provider Demographics
NPI:1366211591
Name:WALTON, CONNIE LEANN (RN, LMT)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:LEANN
Last Name:WALTON
Suffix:
Gender:F
Credentials:RN, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20379 COUNTY ROAD 1590
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-0443
Mailing Address - Country:US
Mailing Address - Phone:580-399-3594
Mailing Address - Fax:
Practice Address - Street 1:1414 ARLINGTON ST STE 2200
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2694
Practice Address - Country:US
Practice Address - Phone:580-399-3594
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0114751163WC0200X, 163WE0003X, 163WM1400X
197627225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist