MEDICARE: PATRICIA WALLER APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	125711	AR

General Provider Information

NPI Number	:	1275151524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA WALLER APRN

Provider Business Mailing Address
First Line	:	905 LONG BRANCH RD
Second Line	:
City	:	HEBER SPRINGS
State	:	AR
Zip	:	72543-8305
Country	:	US
Telephone Number	:	501-206-9019
Fax Number	:

Provider Business Practice Location Address
First Line	:	905 LONG BRANCH RD
Second Line	:
City	:	HEBER SPRINGS
State	:	AR
Zip	:	72543-8305
Country	:	US
Telephone Number	:	501-206-9019
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2020
Last Update Date	:	06/16/2022

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