Provider Demographics
NPI:1417535535
Name:WALLER, KAYLA RENAE (FNP-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:RENAE
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3858 W PINETREE BLVD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-8823
Mailing Address - Country:US
Mailing Address - Phone:229-413-3301
Mailing Address - Fax:
Practice Address - Street 1:1219 HODGES DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4611
Practice Address - Country:US
Practice Address - Phone:229-413-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-30
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN248191363LF0000X
FLAPRN11011958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily