Provider Demographics
NPI:1740401405
Name:WALLER, CHERYL ANN (MS,RD,LD)
Entity Type:Individual
Prefix:MS
First Name:CHERYL
Middle Name:ANN
Last Name:WALLER
Suffix:
Gender:F
Credentials:MS,RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 LANCASTER RD
Mailing Address - Street 2:PO BOX 300
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-9014
Mailing Address - Country:US
Mailing Address - Phone:740-587-1376
Mailing Address - Fax:
Practice Address - Street 1:500 THOMAS LN
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1419
Practice Address - Country:US
Practice Address - Phone:614-566-5582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD2068133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered