Provider Demographics
NPI:1164012928
Name:WALLING, DEBRA A
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:WALLING
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 1:911 RANDOLPH ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3734
Mailing Address - Country:US
Mailing Address - Phone:440-796-8819
Mailing Address - Fax:
Practice Address - Street 1:911 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3734
Practice Address - Country:US
Practice Address - Phone:440-796-8819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH108413670299Medicaid