Provider Demographics
NPI:1255358875
Name:WALLER, AMY ASTEL (APRN BC)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ASTEL
Last Name:WALLER
Suffix:
Gender:F
Credentials:APRN BC
Other - Prefix:MRS
Other - First Name:AMY
Other - Middle Name:ASTEL
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:APRN BC
Mailing Address - Street 1:20 NE SAINT LUKES BLVD
Mailing Address - Street 2:SUITE #330
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086
Mailing Address - Country:US
Mailing Address - Phone:816-554-3838
Mailing Address - Fax:816-554-1634
Practice Address - Street 1:20 NE SAINT LUKES BLVD
Practice Address - Street 2:SUITE #330
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086
Practice Address - Country:US
Practice Address - Phone:816-554-3838
Practice Address - Fax:816-554-1634
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO136973363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT42B408Medicare ID - Type Unspecified