1194974188 NPI number — MRS. CHRISTAL ALANTHA WALLER APN

Table of content: MRS. CHRISTAL ALANTHA WALLER APN (NPI 1194974188)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194974188 NPI number — MRS. CHRISTAL ALANTHA WALLER APN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WALLER
Provider First Name:
CHRISTAL
Provider Middle Name:
ALANTHA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WALLER
Provider Other First Name:
CHRISTAL
Provider Other Middle Name:
SAFFORD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1194974188
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 732892
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75373-4291
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 BAPTIST WAY STE 4C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-2274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
448-227-6450
Provider Business Practice Location Address Fax Number:
448-227-9770
Provider Enumeration Date:
09/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APRN11026008 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A03113 . This is a "ARKANSAS STATE BOARD OF NURSING" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".
  • Identifier: AP09037 . This is a "ADVANCED PRACTICE REGISTERED NURSE" identifier , issued by the state of ( LA ) . This identifiers is of the category "OTHER".
  • Identifier: 120366600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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