MEDICARE: NANCY JANE WALLER CRNFA

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	163WR0006X	Registered Nurse First Assistant		OR

General Provider Information

NPI Number	:	1487707618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY JANE WALLER CRNFA

Provider Business Mailing Address
First Line	:	10940 SW BARNES RD
Second Line	:	PMB 261
City	:	PORTLAND
State	:	OR
Zip	:	97225-5368
Country	:	US
Telephone Number	:	503-706-6660
Fax Number	:

Provider Business Practice Location Address
First Line	:	10940 SW BARNES RD
Second Line	:	PMB 261
City	:	PORTLAND
State	:	OR
Zip	:	97225-5368
Country	:	US
Telephone Number	:	503-706-6660
Fax Number	:	503-469-9176

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	07/08/2007

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