Healthcare Provider Details

I. General information

NPI: 1316427081
Provider Name (Legal Business Name): SERENA WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MEADOW LAKE RD
LOS LUNAS NM
87031-9449
US

IV. Provider business mailing address

112 MEADOW LAKE RD
LOS LUNAS NM
87031-9449
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-9652
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number88832
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: