Provider Demographics
NPI:1619410982
Name:WALLER, TABITHA (FNP)
Entity Type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 W HARVARD AVE
Mailing Address - Street 2:SUITE 241
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:SUITE 241
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2752
Practice Address - Country:US
Practice Address - Phone:541-440-6390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20160204NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20160204NP-PPOtherSTATE LICENSE