Basic Information
| Provider Information | |||||||||
| NPI: | 1457952558 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLER | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3804 HIGHWAY 377 S | ||||||||
| Address2: | |||||||||
| City: | BROWNWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768015120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3252030072 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3804 HIGHWAY 377 S | ||||||||
| Address2: | |||||||||
| City: | BROWNWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 768015120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3256435167 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2020 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1018050 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.