Wall, Staci L

Wall, Staci L is an individual health care provider with primary practice located at 7988 W Jefferson Blvd , Fort Wayne IN 46804-4140. She recently has 2 registered licenses in different health care specialties including Nursing Service Providers / Registered Nurse, Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner. Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner is her primary health care specialty. Wall, Staci L can be contacted via phone (260) 432-4400.

Contact Information

Primary practice address
7988 W Jefferson Blvd Fort Wayne IN 46804-4140
Phone: (260) 432-4400
Fax: (260) 969-6898
Website:
Map and Directions

Health care specialties

SpecialtyCodeLicense #State
Nursing Service Providers / Registered Nurse 163W00000X 28086186 Indiana
Physician Assistants & Advanced Practice Nursing Providers / Nurse Practitioner 363L00000X 71003769 Indiana

Profile Details

NPI number 1629068291
LBN Legal business name Wall, Staci L
Credentials Nurse Practitioner (NP)
Entity Individual
Sole proprietor 1 No
Enumeration date Oct 25th, 2005
Last updated Jan 31st, 2018 - about 6 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1629068291 NPPES
Indiana MEDICAID 200338300

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