Provider Demographics
NPI:1972364586
Name:WALTERS, KRYSTAL NELLA (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:NELLA
Last Name:WALTERS
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16938 WHITE HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-2364
Mailing Address - Country:US
Mailing Address - Phone:734-837-4741
Mailing Address - Fax:
Practice Address - Street 1:30805 ANN ARBOR TRL
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-2482
Practice Address - Country:US
Practice Address - Phone:734-744-7084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-22
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704323078363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care