Basic Information
| Provider Information | |||||||||
| NPI: | 1912350935 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | LEE ANN | ||||||||
| MiddleName: | FULPER | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULPER | ||||||||
| OtherFirstName: | LEE ANN | ||||||||
| OtherMiddleName: | BENNETT | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 415 36TH ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261011005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049173660 | ||||||||
| FaxNumber: | 3049173674 | ||||||||
| Practice Location | |||||||||
| Address1: | 47 DEPOT ST | ||||||||
| Address2: | |||||||||
| City: | CHATHAM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 245315518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344320028 | ||||||||
| FaxNumber: | 4344320062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2016 | ||||||||
| LastUpdateDate: | 07/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305208101 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.