Basic Information
| Provider Information | |||||||||
| NPI: | 1972971018 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | KATIE | ||||||||
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| Credential: | F.N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | ATTN: CREDENTIALING PAYER ENROLLMENT | ||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1321 COTTONWOOD ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | WOODLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306682600 | ||||||||
| FaxNumber: | 5306612410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2015 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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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 | 363LF0000X | 95002750 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.