Healthcare Provider Details

I. General information

NPI: 1114105855
Provider Name (Legal Business Name): HEATHER WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 02/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 NATURE WALK PKWY SUITE 101
ST AUGUSTINE FL
32092-5073
US

IV. Provider business mailing address

111 NATURE WALK PKWY SUITE 101
ST AUGUSTINE FL
32092-5073
US

V. Phone/Fax

Practice location:
  • Phone: 904-230-7761
  • Fax: 904-230-7763
Mailing address:
  • Phone: 904-230-7761
  • Fax: 904-230-7763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA9324
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: