Provider Demographics
NPI:1104233949
Name:WALLER, BRENDA DIANE (RN)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:DIANE
Last Name:WALLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-3210
Mailing Address - Country:US
Mailing Address - Phone:423-322-0166
Mailing Address - Fax:
Practice Address - Street 1:HWY 160/163 BUILDING KA 2010
Practice Address - Street 2:
Practice Address - City:KAYENTA
Practice Address - State:AZ
Practice Address - Zip Code:86033-0368
Practice Address - Country:US
Practice Address - Phone:928-697-4100
Practice Address - Fax:928-697-4029
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000037956163W00000X
AKNURR34341163W00000X, 163WE0003X
TN37956163WE0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ060012Medicaid
AZ060012Medicaid
AZ030073Medicare Oscar/Certification