Basic Information
| Provider Information | |||||||||
| NPI: | 1194774190 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 DEMOSS STREET | ||||||||
| Address2: | |||||||||
| City: | LORDSBURG | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880454600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755428384 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 HIGHLAND BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | NATCHEZ | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391204600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013042421 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 01/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP04732 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | R853759 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | CNP65978 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1343447 | 05 | LA | MEDICAID | 04705271 | 05 | MS | MEDICAID |