MEDICARE: GARY A WALLER LPN

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
1	164W00000X	Licensed Practical Nurse	PN.154227-M-IV	OH

General Provider Information

NPI Number	:	1235518572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY A WALLER LPN

Provider Business Mailing Address
First Line	:	6503 MARSOL RD
Second Line	:	APT 347
City	:	MAYFIELD HEIGHTS
State	:	OH
Zip	:	44124-3568
Country	:	US
Telephone Number	:	216-373-1459
Fax Number	:

Provider Business Practice Location Address
First Line	:	6503 MARSOL RD
Second Line	:	APT 347
City	:	MAYFIELD HTS
State	:	OH
Zip	:	44124-3568
Country	:	US
Telephone Number	:	216-816-6160
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2015
Last Update Date	:	05/20/2015

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