Provider Demographics
NPI:1588787360
Name:WALLER, DEANNA LOUISE (PTA)
Entity type:Individual
Prefix:MISS
First Name:DEANNA
Middle Name:LOUISE
Last Name:WALLER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2341 EL PRADO TERRACE
Mailing Address - Street 2:
Mailing Address - City:DELTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32763
Mailing Address - Country:US
Mailing Address - Phone:386-747-0645
Mailing Address - Fax:
Practice Address - Street 1:500 GRAND PLAZA
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763
Practice Address - Country:US
Practice Address - Phone:386-775-0855
Practice Address - Fax:386-775-0855
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19131225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant