Provider Demographics
NPI:1790319010
Name:WALLER, DARCI
Entity Type:Individual
Prefix:
First Name:DARCI
Middle Name:
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:PO BOX 330627
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-0627
Mailing Address - Country:US
Mailing Address - Phone:904-318-8041
Mailing Address - Fax:866-730-7983
Practice Address - Street 1:3505 WATERCHASE WAY E
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-0802
Practice Address - Country:US
Practice Address - Phone:904-318-8041
Practice Address - Fax:866-730-7983
Is Sole Proprietor?:No
Enumeration Date:2020-02-25
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist