Provider Demographics
NPI:1417365347
Name:CRYSTAL WALLER
Entity Type:Organization
Organization Name:CRYSTAL WALLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-609-9421
Mailing Address - Street 1:3040 CHARLES CARR PL
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-4106
Mailing Address - Country:US
Mailing Address - Phone:216-609-9421
Mailing Address - Fax:
Practice Address - Street 1:3040 CHARLES CARR PL
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-4106
Practice Address - Country:US
Practice Address - Phone:216-609-9421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN141935251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care