Provider Demographics
NPI:1295582336
Name:WALLER, RUTHINA (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:RUTHINA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:RUTHINA
Other - Middle Name:
Other - Last Name:ALSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:8971 CHAMPIONSHIP DR
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-8656
Mailing Address - Country:US
Mailing Address - Phone:810-515-4811
Mailing Address - Fax:
Practice Address - Street 1:1040 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-5516
Practice Address - Country:US
Practice Address - Phone:810-553-9267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704250118163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse