Provider Demographics
NPI:1194774190
Name:WALLER, ANGELA O (FNP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:O
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DEMOSS STREET
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-4600
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:
Practice Address - Street 1:300 HIGHLAND BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4600
Practice Address - Country:US
Practice Address - Phone:601-304-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04732363L00000X
MSR853759363LF0000X
NMCNP65978363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1343447Medicaid
MS04705271Medicaid