| Doctor Name: | CLANCY WALLERSON |
| NPI Number: | 1407168776 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 5510351 |
| Business Practice Address: | 22011 145th Rd Springfield Gardens, NY - 114133420 |
| Business Phone Number: | 3477482184 |
| Business Fax Number: | |
| Mailing Address: | 22011 145th Rd, SPRINGFIELD GARDENS |
| State: | NY |
| Postal Code: | 114133420 |
| Phone Number: | 3477482184 |
| Fax Number: | |
| NPI Enumeration Date: | 07/02/2010 |
| NPI Last Update Date: | 07/02/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 163WS0200X |
| License Number: | 5510351 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Nursing Service Providers |
| Taxonomy Classification: | Registered Nurse |
| Taxonomy Specialization: | School |
| Taxonomy Definition: | |