Provider Demographics
NPI:1609277888
Name:WALLER, SANDRA (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3106 MEMORIAL AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-3730
Mailing Address - Country:US
Mailing Address - Phone:434-845-4448
Mailing Address - Fax:
Practice Address - Street 1:3106 MEMORIAL AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-3730
Practice Address - Country:US
Practice Address - Phone:434-845-4448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA12010807831744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management