Provider Demographics
NPI:1730268780
Name:WALLER, BIANCA NICOLE (DC)
Entity type:Individual
Prefix:
First Name:BIANCA
Middle Name:NICOLE
Last Name:WALLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:STE J-4
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-1500
Mailing Address - Country:US
Mailing Address - Phone:404-691-8881
Mailing Address - Fax:404-619-8999
Practice Address - Street 1:3050 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:STE J-4
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1500
Practice Address - Country:US
Practice Address - Phone:404-691-8881
Practice Address - Fax:404-619-8999
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007925111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor