Provider Demographics
NPI:1992132880
Name:BOYER-WALKER, DIANE MARIE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARIE
Last Name:BOYER-WALKER
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:PO BOX 520983
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99652-0983
Mailing Address - Country:US
Mailing Address - Phone:907-892-0794
Mailing Address - Fax:907-892-0794
Practice Address - Street 1:11269 WASEY WAY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:AK
Practice Address - Zip Code:99694
Practice Address - Country:US
Practice Address - Phone:907-892-0794
Practice Address - Fax:907-892-0794
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100388310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKRL2365Medicaid