Healthcare Provider Details

I. General information

NPI: 1033008180
Provider Name (Legal Business Name): ASHLEY TIERRA WALLER MSN, APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3633 WHEELER RD STE 365
AUGUSTA GA
30909-6549
US

IV. Provider business mailing address

209 W HAVEN DR
KATHLEEN GA
31047-3122
US

V. Phone/Fax

Practice location:
  • Phone: 706-432-6866
  • Fax:
Mailing address:
  • Phone: 478-508-5523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN-NP286520
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN286520
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: