Provider Demographics
NPI:1588452460
Name:WALLER, MAIYE TA'KIYAH
Entity type:Individual
Prefix:
First Name:MAIYE
Middle Name:TA'KIYAH
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 1:619 90TH AVE N APT 6
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-3056
Mailing Address - Country:US
Mailing Address - Phone:727-253-7729
Mailing Address - Fax:
Practice Address - Street 1:111 2ND AVE N STE 360
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3315
Practice Address - Country:US
Practice Address - Phone:727-253-7729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula