Provider Demographics
NPI:1275082430
Name:WALLER, TIFFANY BETTS (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:BETTS
Last Name:WALLER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 LAKESHORE DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-8803
Mailing Address - Country:US
Mailing Address - Phone:205-871-6926
Mailing Address - Fax:205-871-7981
Practice Address - Street 1:2200 LAKESHORE DR
Practice Address - Street 2:SUITE 150
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-8803
Practice Address - Country:US
Practice Address - Phone:205-871-6926
Practice Address - Fax:205-871-7981
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-137729363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health