Basic Information
| Provider Information | |||||||||
| NPI: | 1194974188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | CHRISTAL | ||||||||
| MiddleName: | ALANTHA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
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| OtherLastName: | WALLER | ||||||||
| OtherFirstName: | CHRISTAL | ||||||||
| OtherMiddleName: | SAFFORD | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1330 W MCNEESE ST | ||||||||
| Address2: | APT. 10107 | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706054291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016039600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2000 OPELOUSAS ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706012641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016039600 | ||||||||
| FaxNumber: | 3373101161 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 12/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | A03113 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LW0102X | AP09037 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363LF0000X | AP09037 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | AP09037 | 01 | LA | ADVANCED PRACTICE REGISTERED NURSE | OTHER | A03113 | 01 | AR | ARKANSAS STATE BOARD OF NURSING | OTHER | MW1834375 | 01 | DRUG ENFORCEMENT ADMINISTRATION | OTHER |