Provider Demographics
NPI:1730635681
Name:WALLER, KENSIE (FNP)
Entity Type:Individual
Prefix:
First Name:KENSIE
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KENSIE
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 3299
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-3299
Mailing Address - Country:US
Mailing Address - Phone:317-782-1577
Mailing Address - Fax:317-780-5538
Practice Address - Street 1:3834 S. EMERSON AVE
Practice Address - Street 2:BLDG C, STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203
Practice Address - Country:US
Practice Address - Phone:317-782-1577
Practice Address - Fax:317-780-5538
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28216896A163W00000X
IN71006978A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicaid
INPENDINGOtherANTHEM PROVIDER NUMBER
INPENDINGOtherANTHEM PROVIDER NUMBER