Basic Information
Provider Information
NPI: 1003139510
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WALKER
FirstName: JEWELL
MiddleName: ALLEN
NamePrefix:  
NameSuffix:  
Credential: WHNP, CNM
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 83 UPPER RIVERDALE ROAD
Address2: BLDG 2 SUITE 135
City: RIVERDALE
State: GA
PostalCode: 30274
CountryCode: US
TelephoneNumber: 7709910778
FaxNumber:  
Practice Location
Address1: 83 UPPER RIVERDALE ROAD
Address2: BLDG 2 SUITE 135
City: RIVERDALE
State: GA
PostalCode: 30274
CountryCode: US
TelephoneNumber: 7709910778
FaxNumber:  
Other Information
ProviderEnumerationDate: 03/11/2010
LastUpdateDate: 03/11/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
176B00000XRN044181GAN Other Service ProvidersMidwife 
364SW0102XRN044181GAY Physician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistWomen's Health

No ID Information.


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