Provider Demographics
NPI:1558594085
Name:WALLER, GLENDA JOYCE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:GLENDA
Middle Name:JOYCE
Last Name:WALLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 LILLY RD NE # 204
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5101
Mailing Address - Country:US
Mailing Address - Phone:360-493-4002
Mailing Address - Fax:360-493-5524
Practice Address - Street 1:525 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5101
Practice Address - Country:US
Practice Address - Phone:360-493-7230
Practice Address - Fax:360-493-4180
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60100021363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily