Provider Demographics
NPI:1912728163
Name:WALTERS, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WALTERS
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 1:104 SHADOW RIDGE CT # 2
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD BAY
Mailing Address - State:AR
Mailing Address - Zip Code:72088-3656
Mailing Address - Country:US
Mailing Address - Phone:501-362-4332
Mailing Address - Fax:
Practice Address - Street 1:104 SHADOW RIDGE CT # 2
Practice Address - Street 2:
Practice Address - City:FAIRFIELD BAY
Practice Address - State:AR
Practice Address - Zip Code:72088-3656
Practice Address - Country:US
Practice Address - Phone:501-362-4332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4953225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist