Provider Demographics
NPI:1639824907
Name:WALLER, CEDRIC R
Entity Type:Individual
Prefix:
First Name:CEDRIC
Middle Name:R
Last Name:WALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 ASHMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28081
Mailing Address - Country:US
Mailing Address - Phone:901-491-5007
Mailing Address - Fax:
Practice Address - Street 1:171 ASHMOUNT DR
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28081
Practice Address - Country:US
Practice Address - Phone:901-491-5007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education