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General NPI Number Information
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NPI Number | 1306931738
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Entity Type | Individual
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Provider Name | ANGELIQUE GLOSTER WALLER M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 8250 KENWOOD CROSSING WAY #205
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City | CINCINNATI
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State | OH
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Zip | 45236
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Country | US
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Telephone | 513-948-8444
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Fax | 513-948-0756
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Provider Business Mailing Address
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Address Line | 12061 SHERATON LN
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City | CINCINNATI
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State | OH
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Zip | 45246-1611
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Country | US
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Telephone | 513-336-6700
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 35-067334
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License Number State | OH
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