Provider Demographics
NPI:1508425224
Name:WALLER, ARTISHA JENEAL
Entity Type:Individual
Prefix:
First Name:ARTISHA
Middle Name:JENEAL
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 1:18039 NEFF RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44119-2663
Mailing Address - Country:US
Mailing Address - Phone:216-224-2246
Mailing Address - Fax:
Practice Address - Street 1:18039 NEFF RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44119-2663
Practice Address - Country:US
Practice Address - Phone:216-224-2246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401640830514376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0143457OtherINDEPENDENT PROVIDER NUMBER