Provider Demographics
NPI:1356762728
Name:WALLER, KAYLEE (CRNA)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14850 QUORUM DR STE 400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-1445
Mailing Address - Country:US
Mailing Address - Phone:469-437-3564
Mailing Address - Fax:469-825-6903
Practice Address - Street 1:14850 QUORUM DR STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-1445
Practice Address - Country:US
Practice Address - Phone:469-437-3564
Practice Address - Fax:469-825-6903
Is Sole Proprietor?:No
Enumeration Date:2014-01-02
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100315367500000X
NC742739367500000X
TX742739367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered