Provider Demographics
NPI:1740966894
Name:WALLER, MIRIAM ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:MIRIAM
Middle Name:ELIZABETH
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 GREEN OAK DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-3719
Mailing Address - Country:US
Mailing Address - Phone:304-544-3362
Mailing Address - Fax:
Practice Address - Street 1:9154 US ROUTE 60
Practice Address - Street 2:
Practice Address - City:ONA
Practice Address - State:WV
Practice Address - Zip Code:25545-7416
Practice Address - Country:US
Practice Address - Phone:304-733-9430
Practice Address - Fax:304-733-9439
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV63047163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health