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NPI Code Detail

MEDICARE: MS. CRYSTAL MICHELLE WALLER LPN

MEDICARE: MS. CRYSTAL MICHELLE WALLER LPN
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
1164W00000XLicensed Practical NursePN.141935OH

General Provider Information

NPI Number : 1619273158
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. CRYSTAL MICHELLE WALLER LPN
Provider Business Mailing Address
First Line : 8014 CORY AVE
Second Line :
City : CLEVELAND
State : OH
Zip : 44103-3436
Country : US
Telephone Number : 216-862-2210
Fax Number :
Provider Business Practice Location Address
First Line : 8014 CORY AVE
Second Line :
City : CLEVELAND
State : OH
Zip : 44103-3436
Country : US
Telephone Number : 216-862-2210
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/01/2011
Last Update Date : 02/01/2011

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