Provider Demographics
NPI:1750270500
Name:WALLER, FAY MARSHELLE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:FAY
Middle Name:MARSHELLE
Last Name:WALLER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 WALLEN HILLS DR APT 4
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-7033
Mailing Address - Country:US
Mailing Address - Phone:260-446-4898
Mailing Address - Fax:
Practice Address - Street 1:5614 INDUSTRIAL RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5126
Practice Address - Country:US
Practice Address - Phone:260-205-8000
Practice Address - Fax:260-205-8820
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-28
Last Update Date:2025-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28214217A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily