Individual
KENSIE WALLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
3834 S. EMERSON AVE, BLDG C, STE 100, INDIANAPOLIS, IN 46203
(317) 782-1577
(317) 780-5538
Mailing address
PO BOX 3299, CARSON CITY, NV 89702-3299
(317) 782-1577
(317) 780-5538
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
28216896A
IN
363LF0000X
Family Nurse Practitioner
Primary
71006978A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PENDING
ANTHEM PROVIDER NUMBER
IN
05
—
PENDING
—
IN
Enumeration date
08/31/2016
Last updated
08/01/2018
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