Provider Demographics
NPI:1902386741
Name:WALLER, SANDIA MARIE
Entity Type:Individual
Prefix:DR
First Name:SANDIA
Middle Name:MARIE
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 1:5064 LIVERMORE RD
Mailing Address - Street 2:
Mailing Address - City:CLIFFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48727-9512
Mailing Address - Country:US
Mailing Address - Phone:989-721-7820
Mailing Address - Fax:
Practice Address - Street 1:168 N SAGINAW ST STE B
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-4613
Practice Address - Country:US
Practice Address - Phone:810-969-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0450133V00000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered