Provider Demographics
NPI:1508516220
Name:WALLER, SHARON
Entity Type:Individual
Prefix:
First Name:SHARON
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:PO BOX 831
Mailing Address - Street 2:
Mailing Address - City:AROMAS
Mailing Address - State:CA
Mailing Address - Zip Code:95004-0831
Mailing Address - Country:US
Mailing Address - Phone:831-235-0484
Mailing Address - Fax:
Practice Address - Street 1:471 ROSE AVENUE
Practice Address - Street 2:
Practice Address - City:AROMAS
Practice Address - State:CA
Practice Address - Zip Code:95004-9500
Practice Address - Country:US
Practice Address - Phone:831-235-0484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7162235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist