Provider Demographics
NPI:1417220625
Name:WALTHALL, MICA (LPN)
Entity type:Individual
Prefix:
First Name:MICA
Middle Name:
Last Name:WALTHALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MALER LN
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3558
Mailing Address - Country:US
Mailing Address - Phone:631-639-6682
Mailing Address - Fax:
Practice Address - Street 1:2 MALER LN
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3558
Practice Address - Country:US
Practice Address - Phone:631-639-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270772164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse