Provider Demographics
NPI:1639519630
Name:WALLER, CARMON JEAN (CPM)
Entity Type:Individual
Prefix:MRS
First Name:CARMON
Middle Name:JEAN
Last Name:WALLER
Suffix:
Gender:F
Credentials:CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4814 BEACH DR SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4343
Mailing Address - Country:US
Mailing Address - Phone:206-963-1028
Mailing Address - Fax:
Practice Address - Street 1:4814 BEACH DR SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4343
Practice Address - Country:US
Practice Address - Phone:206-963-1028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife