Provider Demographics
NPI:1295488468
Name:WALLER, ZACHARY
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 PARKCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY ISLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72631-8045
Mailing Address - Country:US
Mailing Address - Phone:147-936-3642
Mailing Address - Fax:
Practice Address - Street 1:23 PARKCLIFF DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY ISLAND
Practice Address - State:AR
Practice Address - Zip Code:72631-8045
Practice Address - Country:US
Practice Address - Phone:147-936-3642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist