Provider Demographics
NPI:1750270500
Name:WALLER, FAY MARSHELLE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:FAY
Middle Name:MARSHELLE
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2413 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-5854
Mailing Address - Country:US
Mailing Address - Phone:317-924-5250
Mailing Address - Fax:317-924-5251
Practice Address - Street 1:3417 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4830
Practice Address - Country:US
Practice Address - Phone:260-387-6218
Practice Address - Fax:260-387-6352
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-28
Last Update Date:2025-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71016908A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily