Provider Demographics
NPI:1699079046
Name:WALLER, CORENNA LOUISE
Entity type:Individual
Prefix:
First Name:CORENNA
Middle Name:LOUISE
Last Name:WALLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 E KINGS CANYON RD
Mailing Address - Street 2:BLDG 319
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93702-3604
Mailing Address - Country:US
Mailing Address - Phone:559-453-6227
Mailing Address - Fax:559-452-8901
Practice Address - Street 1:4411 E KINGS CANYON RD
Practice Address - Street 2:BLDG 319
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93702-3604
Practice Address - Country:US
Practice Address - Phone:559-453-6227
Practice Address - Fax:559-452-8901
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist