Provider Demographics
NPI:1215770516
Name:WALLER, RICHARD KEITH (APRN)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:KEITH
Last Name:WALLER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2123 AUBURN AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219-2906
Mailing Address - Country:US
Mailing Address - Phone:513-241-5630
Mailing Address - Fax:513-241-7146
Practice Address - Street 1:11135 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45249-2338
Practice Address - Country:US
Practice Address - Phone:513-791-7572
Practice Address - Fax:513-791-8240
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0036149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily