Provider Demographics
NPI:1902386741
Name:WALLER, SANDIA MARIE
Entity type:Individual
Prefix:DR
First Name:SANDIA
Middle Name:MARIE
Last Name:WALLER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5064 LIVERMORE RD
Mailing Address - Street 2:
Mailing Address - City:CLIFFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48727-9512
Mailing Address - Country:US
Mailing Address - Phone:989-721-7820
Mailing Address - Fax:
Practice Address - Street 1:5064 LIVERMORE RD
Practice Address - Street 2:
Practice Address - City:CLIFFORD
Practice Address - State:MI
Practice Address - Zip Code:48727-9512
Practice Address - Country:US
Practice Address - Phone:989-721-7820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501001646225700000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist