Provider Demographics
NPI:1225202286
Name:WALLER, DIANA L (DC)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:WALLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7312 W CHEYENNE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-7428
Mailing Address - Country:US
Mailing Address - Phone:702-463-2223
Mailing Address - Fax:702-463-2221
Practice Address - Street 1:7312 W CHEYENNE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7428
Practice Address - Country:US
Practice Address - Phone:702-463-2223
Practice Address - Fax:702-463-2221
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB00909111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor