Provider Demographics
NPI:1356329973
Name:WALLER, MARY B (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:WALLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 HALLMARK DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-3317
Mailing Address - Country:US
Mailing Address - Phone:850-470-9615
Mailing Address - Fax:850-470-9615
Practice Address - Street 1:1000 W MORENO ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2316
Practice Address - Country:US
Practice Address - Phone:850-434-4858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2947442367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302213700Medicaid
FLG2209OtherBSFL
FLG2209OtherBSFL