Healthcare Provider Details

I. General information

NPI: 1457463861
Provider Name (Legal Business Name): CARRIE E WALLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 W ARLINGTON BLVD STE 106
GREENVILLE NC
27834-4168
US

IV. Provider business mailing address

2609 W ARLINGTON BLVD STE 106
GREENVILLE NC
27834-4168
US

V. Phone/Fax

Practice location:
  • Phone: 252-689-6303
  • Fax: 252-689-6304
Mailing address:
  • Phone: 252-689-6303
  • Fax: 252-689-6304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number200401596
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200401596
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: