Provider Demographics
NPI:1306179015
Name:WALLER, LAURA KATHERINE (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:KATHERINE
Last Name:WALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:427B SAN ANSELMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2611
Mailing Address - Country:US
Mailing Address - Phone:415-990-1579
Mailing Address - Fax:
Practice Address - Street 1:427B SAN ANSELMO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-2611
Practice Address - Country:US
Practice Address - Phone:415-990-1579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-13
Last Update Date:2009-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0653842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry