Provider Demographics
NPI:1275151524
Name:WALLER, PATRICIA (APRN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 LONG BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-8305
Mailing Address - Country:US
Mailing Address - Phone:501-206-9019
Mailing Address - Fax:
Practice Address - Street 1:905 LONG BRANCH RD
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-8305
Practice Address - Country:US
Practice Address - Phone:501-206-9019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR125711363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner