Provider Demographics
NPI:1013971324
Name:WALLER, AMELIA B (ARNP)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:B
Last Name:WALLER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 SE 3RD AVE # 601
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2521
Mailing Address - Country:US
Mailing Address - Phone:954-712-1115
Mailing Address - Fax:954-462-5413
Practice Address - Street 1:1625 SE 3RD AVE # 601
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2521
Practice Address - Country:US
Practice Address - Phone:954-712-1115
Practice Address - Fax:954-462-5413
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2173192363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP05269Medicare UPIN
FLE4027VMedicare ID - Type Unspecified