Healthcare Provider Details

I. General information

NPI: 1891716312
Provider Name (Legal Business Name): SUSAN KAY HALLEY MS, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 HOBSON RD HERITAGE PARK
FORT WAYNE IN
46805-4872
US

IV. Provider business mailing address

2011 OTSEGO DR
FORT WAYNE IN
46825-3844
US

V. Phone/Fax

Practice location:
  • Phone: 260-484-9557
  • Fax:
Mailing address:
  • Phone: 260-483-2287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000658
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: