Individual ProviderMica WalthallLicensed Practical NurseNursing Service ProvidersPractice Address2 Maler Ln, Patchogue, NY 11772-3558(631) 639-6682PECOS EnrollmentBased on the most recent information from CMS, provider Mica Walthall does not have current enrollment records in PECOS.Part BMedicare Part BNot EnrolledHHAHome Health AgencyNot EnrolledDMEDurable Medical EquipmentNot EnrolledPMDPower Mobility DeviceNot EnrolledCMS last updated its PECOS records 2 days ago.Profile DetailsProvider ID1417220625Provider TypeIndividualFull NameWalthall, MicaCredentialLPNGenderFemaleSole ProprietorYesEnumeration Date2/17/2012Last Updated2/17/2012Contact InformationPractice LocationPractice Address2 Maler Ln, Patchogue, NY 11772-3558Phone(631) 639-6682FaxUnlisted FaxMailing LocationMailing Address2 Maler Ln, Patchogue, NY 11772-3558Phone(631) 639-6682FaxUnlisted FaxProvider TaxonomiesCodeDescriptionLicenseCode164W00000XPrimaryDescriptionLicensed Practical NurseNursing Service ProvidersLicense270772New York