Provider Demographics
NPI:1053622167
Name:WALLER, HOLLI DEZAUN (DO)
Entity type:Individual
Prefix:MRS
First Name:HOLLI
Middle Name:DEZAUN
Last Name:WALLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HOLLI
Other - Middle Name:DEZAUN
Other - Last Name:HOLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6326 STONEWOOD POINTE LN.
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77066
Mailing Address - Country:US
Mailing Address - Phone:281-300-9849
Mailing Address - Fax:
Practice Address - Street 1:3700 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060
Practice Address - Country:US
Practice Address - Phone:540-953-5445
Practice Address - Fax:540-953-5453
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116022785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine