Healthcare Provider Details

I. General information

NPI: 1366996894
Provider Name (Legal Business Name): ANNA WALLER CFY-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2016
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 NE 65TH AVE
VANCOUVER WA
98661-6812
US

IV. Provider business mailing address

33 SCHMID RD
TROUT LAKE WA
98650-9717
US

V. Phone/Fax

Practice location:
  • Phone: 360-750-7500
  • Fax:
Mailing address:
  • Phone: 509-637-3038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number530553G
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: