Provider Demographics
NPI:1518090307
Name:WALLER, SANDRA FAY
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:FAY
Last Name:WALLER
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 1:5434 SHREVEPORT HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-3532
Mailing Address - Country:US
Mailing Address - Phone:318-641-6706
Mailing Address - Fax:318-484-6228
Practice Address - Street 1:2129 RAINBOW DR
Practice Address - Street 2:242 W SHAMROCK STREET
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-6449
Practice Address - Country:US
Practice Address - Phone:318-484-6469
Practice Address - Fax:318-484-6228
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider