Provider Demographics
NPI:1912350935
Name:WALLER, LEE ANN FULPER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:LEE ANN
Middle Name:FULPER
Last Name:WALLER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:LEE ANN
Other - Middle Name:BENNETT
Other - Last Name:FULPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:415 36TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-1005
Mailing Address - Country:US
Mailing Address - Phone:304-917-3660
Mailing Address - Fax:304-917-3674
Practice Address - Street 1:47 DEPOT ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:VA
Practice Address - Zip Code:24531-5518
Practice Address - Country:US
Practice Address - Phone:434-432-0028
Practice Address - Fax:434-432-0062
Is Sole Proprietor?:No
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305208101225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist