Provider Demographics
NPI:1518699628
Name:HALLER, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:HALLER
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 1:463 SLAB CAMP RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:WV
Mailing Address - Zip Code:26374-7038
Mailing Address - Country:US
Mailing Address - Phone:304-988-4200
Mailing Address - Fax:
Practice Address - Street 1:463 SLAB CAMP RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:WV
Practice Address - Zip Code:26374-7038
Practice Address - Country:US
Practice Address - Phone:304-988-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker