Healthcare Provider Details

I. General information

NPI: 1023027778
Provider Name (Legal Business Name): KATHLENE SUE WALLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HARTSHORN HEALTH SERVICE COLORADO STATE UNIVERSITY
FORT COLLINS CO
80523-8031
US

IV. Provider business mailing address

HARTSHORN HEALTH SERVICE COLORADO STATE UNIVERSITY
FORT COLLINS CO
80523-8031
US

V. Phone/Fax

Practice location:
  • Phone: 970-491-7121
  • Fax: 970-491-0226
Mailing address:
  • Phone: 970-491-7121
  • Fax: 970-491-0226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number30233
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: