Healthcare Provider Details

I. General information

NPI: 1285354985
Provider Name (Legal Business Name): ANSLEY WALLER MSN, APRN, AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 HIGHWAY 121 STE 201
BEDFORD TX
76021-5011
US

IV. Provider business mailing address

3801 WILLIAM D TATE AVE STE 105
GRAPEVINE TX
76051-8755
US

V. Phone/Fax

Practice location:
  • Phone: 817-283-5166
  • Fax: 817-283-5176
Mailing address:
  • Phone: 817-488-6812
  • Fax: 817-251-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1097452
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number1097452
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: