Most Relevant Information
Provider Data
| NPI Number: | 1003411661 |
| Provider Name: | MARY BETH WALLER |
| Entity Type: | Individual |
| Taxonomy Code: | 3747A0650X |
| Specialty: | Technician |
| License Number: |
Most Important Dates
| Enumeration Date: | 12/02/2020 |
| Last Updated: | 12/02/2020 |
Provider Practice Location
1471 BOAT DOCK RD
SOMERSET
KY
425019246
Practice Location Phone/Fax
| Phone: | 6064927620 |
| Fax: |
Provider Mailing Location
1471 BOAT DOCK RD
SOMERSET
KY
425019246
Provider Mailing Phone/Fax
| Phone: | 6064927620 |
| Fax: |