Provider Demographics
NPI:1306480884
Name:WALLER, TAMARA (PT)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SUNRISE BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23430
Mailing Address - Country:US
Mailing Address - Phone:757-371-1064
Mailing Address - Fax:
Practice Address - Street 1:107 SUNRISE BLUFF CT
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:VA
Practice Address - Zip Code:23430
Practice Address - Country:US
Practice Address - Phone:757-371-1064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003980225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist