Healthcare Provider Details

I. General information

NPI: 1700721073
Provider Name (Legal Business Name): MCKAYLA NICOLE WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 11/06/2026
Certification Date: 11/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

332 ALAN AYERS RD W
ESTANCIA NM
87016-8099
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2800
  • Fax:
Mailing address:
  • Phone: 505-917-1693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number56704
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number56704
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: