Provider Demographics
NPI:1194974188
Name:WALLER, CHRISTAL ALANTHA (APN)
Entity type:Individual
Prefix:MRS
First Name:CHRISTAL
Middle Name:ALANTHA
Last Name:WALLER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:CHRISTAL
Other - Middle Name:SAFFORD
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 732892
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 BAPTIST WAY STE 4C
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2274
Practice Address - Country:US
Practice Address - Phone:448-227-6450
Practice Address - Fax:448-227-9770
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026008363LF0000X
LAAP09037363LW0102X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARA03113OtherARKANSAS STATE BOARD OF NURSING
LAAP09037OtherADVANCED PRACTICE REGISTERED NURSE
MW1834375OtherDRUG ENFORCEMENT ADMINISTRATION