Provider Demographics
NPI:1043260441
Name:WALLER, SANDRA D (FNP, MSN)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:D
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2595 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-5905
Mailing Address - Country:US
Mailing Address - Phone:901-260-8551
Mailing Address - Fax:901-260-8590
Practice Address - Street 1:2861 BROAD AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-2903
Practice Address - Country:US
Practice Address - Phone:901-260-8500
Practice Address - Fax:901-325-6469
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005098363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3346145Medicaid
TN3346145Medicaid
TNS56025Medicare UPIN