Provider Demographics
NPI:1942915137
Name:WALLER, NATALIE (APRN)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 E INDIAN STONE RD
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40165-9354
Mailing Address - Country:US
Mailing Address - Phone:270-230-7076
Mailing Address - Fax:
Practice Address - Street 1:2525 S TELSHOR BLVD STE 15-202
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5071
Practice Address - Country:US
Practice Address - Phone:888-209-8874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3018933363L00000X
AZ293147363L00000X
ID78565363LF0000X
NM76837363LF0000X
COCRXN.0101059-C-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner