Individual
STACI L WALL
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
7988 W JEFFERSON BLVD, FORT WAYNE, IN 46804-4140
(260) 432-4400
(260) 969-6898
Mailing address
2518 E DUPONT RD, FORT WAYNE, IN 46825-1675
(260) 432-4400
(260) 969-6898
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28086186
IN
363L00000X
Nurse Practitioner
Primary
71003769
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200338300
—
IN
Enumeration date
10/25/2005
Last updated
01/31/2018
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