Healthcare Provider Details

I. General information

NPI: 1225830607
Provider Name (Legal Business Name): LORRAINE MAY WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 N MAIN ST
BARBOURVILLE KY
40906-1445
US

IV. Provider business mailing address

641 MANCHESTER ST
BARBOURVILLE KY
40906-1758
US

V. Phone/Fax

Practice location:
  • Phone: 606-545-7083
  • Fax:
Mailing address:
  • Phone: 606-250-8924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: