Provider Demographics
NPI:1144404807
Name:WALLER, SANDRA KAY (LMT)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:KAY
Last Name:WALLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 W 29TH STREET
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2003
Mailing Address - Country:US
Mailing Address - Phone:850-276-1932
Mailing Address - Fax:
Practice Address - Street 1:1714 W 23RD STREET
Practice Address - Street 2:SUITE E
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2003
Practice Address - Country:US
Practice Address - Phone:850-276-1932
Practice Address - Fax:850-769-8689
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA36353225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist