Healthcare Provider Details

I. General information

NPI: 1417365347
Provider Name (Legal Business Name): CRYSTAL WALLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2014
Last Update Date: 07/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 CHARLES CARR PL
CLEVELAND OH
44104-4106
US

IV. Provider business mailing address

3040 CHARLES CARR PL
CLEVELAND OH
44104-4106
US

V. Phone/Fax

Practice location:
  • Phone: 216-609-9421
  • Fax:
Mailing address:
  • Phone: 216-609-9421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberPN141935
License Number StateOH

VIII. Authorized Official

Name: CRYSTAL MICHELLE WALLER
Title or Position: LPN
Credential:
Phone: 216-609-9421