Provider Demographics
NPI:1962947960
Name:ELYSSA N WALLER
Entity type:Organization
Organization Name:ELYSSA N WALLER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-482-2373
Mailing Address - Street 1:4729 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-6820
Mailing Address - Country:US
Mailing Address - Phone:850-482-2373
Mailing Address - Fax:850-482-2395
Practice Address - Street 1:4729 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-6820
Practice Address - Country:US
Practice Address - Phone:850-482-2373
Practice Address - Fax:850-482-2395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9060111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U1XD4OtherFLORIDA BLUE