Provider Demographics
NPI:1386102432
Name:WALLER, LAURA (ATC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2143 WELLS DR
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-8443
Mailing Address - Country:US
Mailing Address - Phone:541-399-0570
Mailing Address - Fax:
Practice Address - Street 1:615 NE 15TH ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3399
Practice Address - Country:US
Practice Address - Phone:503-565-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORATAT101853132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORATAT10185313OtherOREGON HEALTH LICENCING BOARD