Provider Demographics
NPI:1093794133
Name:WALLER, BRENDA SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:SUE
Last Name:WALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2600 MEMORIAL AVE SUITE 201B
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501
Mailing Address - Country:US
Mailing Address - Phone:434-528-0896
Mailing Address - Fax:434-528-0896
Practice Address - Street 1:2600 MEMORIAL AVE SUITE 201B
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501
Practice Address - Country:US
Practice Address - Phone:434-528-0896
Practice Address - Fax:434-528-0896
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101055485208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation