Provider Demographics
NPI:1548802739
Name:WALLER, SHANNON MORGAN (APRN)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MORGAN
Last Name:WALLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:MORGAN
Other - Last Name:LINDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:43 YAWPO AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-2714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 YAWPO AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436-2714
Practice Address - Country:US
Practice Address - Phone:201-337-0066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00970000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily