Provider Demographics
NPI:1679986988
Name:WALLER, URSULA F
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:F
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MARSHALL RD
Mailing Address - Street 2:
Mailing Address - City:BUCKHEAD
Mailing Address - State:GA
Mailing Address - Zip Code:30625-2906
Mailing Address - Country:US
Mailing Address - Phone:706-473-6192
Mailing Address - Fax:706-485-9254
Practice Address - Street 1:128 MARSHALL RD
Practice Address - Street 2:
Practice Address - City:BUCKHEAD
Practice Address - State:GA
Practice Address - Zip Code:30625-2906
Practice Address - Country:US
Practice Address - Phone:706-473-6192
Practice Address - Fax:706-485-9254
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1540540367500000X
FL9299664367500000X
OHCOA.17161-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered