Provider Demographics
NPI:1235518572
Name:WALLER, GARY A (LPN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:WALLER
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6503 MARSOL RD
Mailing Address - Street 2:APT 347
Mailing Address - City:MAYFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-3568
Mailing Address - Country:US
Mailing Address - Phone:216-373-1459
Mailing Address - Fax:
Practice Address - Street 1:6503 MARSOL RD
Practice Address - Street 2:APT 347
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-3568
Practice Address - Country:US
Practice Address - Phone:216-816-6160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.154227-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse