Healthcare Provider Details

I. General information

NPI: 1306931738
Provider Name (Legal Business Name): ANGELIQUE GLOSTER WALLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8250 KENWOOD CROSSING WAY #205
CINCINNATI OH
45236
US

IV. Provider business mailing address

12061 SHERATON LN
CINCINNATI OH
45246-1611
US

V. Phone/Fax

Practice location:
  • Phone: 513-948-8444
  • Fax: 513-948-0756
Mailing address:
  • Phone: 513-336-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-067334
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: