Provider Demographics
NPI:1003411661
Name:WALLER, MARY BETH
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
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 1:1471 BOAT DOCK RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-9246
Mailing Address - Country:US
Mailing Address - Phone:606-492-7620
Mailing Address - Fax:
Practice Address - Street 1:1471 BOAT DOCK RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-9246
Practice Address - Country:US
Practice Address - Phone:606-492-7620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider