Provider Demographics
NPI:1972649887
Name:WALLING, GUY R (NP NURSE PRACTITIONE)
Entity Type:Individual
Prefix:
First Name:GUY
Middle Name:R
Last Name:WALLING
Suffix:
Gender:M
Credentials:NP NURSE PRACTITIONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12617 OLD STONE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-9317
Mailing Address - Country:US
Mailing Address - Phone:317-652-1400
Mailing Address - Fax:317-355-6096
Practice Address - Street 1:5470 EAST 16TH STREET
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-4861
Practice Address - Country:US
Practice Address - Phone:317-355-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002327A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100270530AMedicaid
IN201086220Medicaid
IN100270530AMedicaid