Staci L Wall, NP
Nurse Practitioner in Fort Wayne, IN. Individual provider (NPI-1).
NPI number1629068291
StatusActive
Last updated in NPPESJan 31, 2018
Details
- NPI
- 1629068291
- Entity type
- Individual (NPI-1)
- Name
- Staci L Wall
- Credential
- NP
- Sex
- Female
- Sole proprietor
- No
- Enumeration date
- Oct 25, 2005
- Last updated
- Jan 31, 2018
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 363L00000X | Nurse Practitioner | 71003769 | IN | Yes |
| 163W00000X | Registered Nurse | 28086186 | IN |
Practice location
7988 W Jefferson BlvdFort Wayne, IN 46804-4140
Phone 260-432-4400 · Fax 260-969-6898
Mailing address
2518 E Dupont RdFort Wayne, IN 46825-1675
Phone 260-432-4400 · Fax 260-969-6898
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