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NPI Code Detail

MEDICARE: AMANDA WALLER

MEDICARE: AMANDA WALLER
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy Assistant2319-19WI

General Provider Information

NPI Number : 1134504657
Entity Type Code : Individual
Provider Name (Legal Business Name) : AMANDA WALLER
Provider Business Mailing Address
First Line : 19 W NEWTON ST
Second Line :
City : RICE LAKE
State : WI
Zip : 54868-1744
Country : US
Telephone Number : 715-234-2161
Fax Number :
Provider Business Practice Location Address
First Line : 19 W NEWTON ST
Second Line :
City : RICE LAKE
State : WI
Zip : 54868-1744
Country : US
Telephone Number : 715-234-2161
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/26/2015
Last Update Date : 07/26/2015

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Directions to “ AMANDA WALLER ” Practice Location

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