Provider Demographics
NPI:1265541536
Name:WALLER, ELYSSA (DC)
Entity type:Individual
Prefix:DR
First Name:ELYSSA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 COMMERCIAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32448-2522
Mailing Address - Country:US
Mailing Address - Phone:850-482-2373
Mailing Address - Fax:
Practice Address - Street 1:2525 COMMERCIAL PARK DR
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32448-2522
Practice Address - Country:US
Practice Address - Phone:850-482-2373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2122111N00000X
FLCH9060111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL76131OtherBCBS
AL51527075OtherBCBS
AL51527075OtherBCBS