Healthcare Provider Details

I. General information

NPI: 1558594085
Provider Name (Legal Business Name): GLENDA JOYCE WALLER ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 LILLY RD NE
OLYMPIA WA
98506-5101
US

IV. Provider business mailing address

525 LILLY RD NE # 204
OLYMPIA WA
98506-5101
US

V. Phone/Fax

Practice location:
  • Phone: 360-493-7230
  • Fax: 360-493-4180
Mailing address:
  • Phone: 360-493-4002
  • Fax: 360-493-5524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60100021
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: