Healthcare Provider Details

I. General information

NPI: 1184885022
Provider Name (Legal Business Name): MRS. KAREN ELAINE WALLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 JETT ST
WEST PORTSMOUTH OH
45663-6213
US

IV. Provider business mailing address

613 JETT ST
WEST PORTSMOUTH OH
45663-6213
US

V. Phone/Fax

Practice location:
  • Phone: 740-858-2828
  • Fax:
Mailing address:
  • Phone: 740-858-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN 113668
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: