Healthcare Provider Details

I. General information

NPI: 1487707618
Provider Name (Legal Business Name): NANCY JANE WALLER CRNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10940 SW BARNES RD PMB 261
PORTLAND OR
97225-5368
US

IV. Provider business mailing address

10940 SW BARNES RD PMB 261
PORTLAND OR
97225-5368
US

V. Phone/Fax

Practice location:
  • Phone: 503-706-6660
  • Fax: 503-469-9176
Mailing address:
  • Phone: 503-706-6660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: