Provider Demographics
NPI:1285354985
Name:WALLER, ANSLEY (MSN, APRN, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:ANSLEY
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:MSN, APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 WILLIAM D TATE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8755
Mailing Address - Country:US
Mailing Address - Phone:817-488-6812
Mailing Address - Fax:817-251-1303
Practice Address - Street 1:2425 HIGHWAY 121 STE 201
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5011
Practice Address - Country:US
Practice Address - Phone:817-283-5166
Practice Address - Fax:817-283-5176
Is Sole Proprietor?:No
Enumeration Date:2022-09-01
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1097452363L00000X, 163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner