Provider Demographics
NPI:1851752539
Name:WALLER, JOAN (LMT)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 THIRD ST
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99801
Mailing Address - Country:US
Mailing Address - Phone:907-957-8557
Mailing Address - Fax:
Practice Address - Street 1:315 THIRD ST
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801
Practice Address - Country:US
Practice Address - Phone:907-957-8557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101902174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist