Provider Demographics
NPI:1407553282
Name:WALLER, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3551 N RIDGE RD E
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4313
Mailing Address - Country:US
Mailing Address - Phone:440-998-4014
Mailing Address - Fax:
Practice Address - Street 1:3551 N RIDGE RD E
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4313
Practice Address - Country:US
Practice Address - Phone:440-998-4014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician