Provider Demographics
NPI:1891716312
Name:HALLEY, SUSAN KAY (MS, FNP-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:KAY
Last Name:HALLEY
Suffix:
Gender:F
Credentials:MS, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 OTSEGO DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-3844
Mailing Address - Country:US
Mailing Address - Phone:260-483-2287
Mailing Address - Fax:
Practice Address - Street 1:2001 HOBSON RD
Practice Address - Street 2:HERITAGE PARK
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4872
Practice Address - Country:US
Practice Address - Phone:260-484-9557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000658363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200239640Medicaid
INS89607Medicare UPIN
IN200239640Medicaid